REPUBLIC OF ZAMBIA
Ministry of Health
ZAMBIA STANDARD TREATMENT GUIDELINE
2020
RECOMMENDED CITATION
Ministry of Health, Zambia National Formulary Committee (2020). Standard Treatment
Guidelines, Essential Medicines List, Essential Laboratory Supplies for Zambia, 5 th
edition. Zambia Ministry of Health, Lusaka.
Electronic copies are available on the Ministry of Health Website:
https://www.moh.gov.zm
Print copies may be obtained from:
Ministry of Health
Ndeke House
Haile Selassie Avenue,
PO Box, 30205, Lusaka Zambia.
The information presented in these guidelines conforms to the current evidencebased practice. Contributors, reviewers and editors cannot be held responsible
for omissions, individual responses to medicines and other consequences. The
views expressed herein do not necessarily represent the views of the Clinton
Health Access Initiative and other cooperating partners that supported the
production of these guidelines.
ii
FOREWORD
Achieving long term improvements in the rational use of medicines and care of
the sick requires building the competences of the health care professionals. This
fourth edition of the Standard Treatment Guidelines is an update of the earlier
version contributing to rational and cost-effective health care designed under
the aspirations and spirit of increasing efficacy of decision making and
precision in prevention, diagnosis, treatment, alleviation of disease and
improved quality of life for the Zambian people as cited in the National Drug
Policy.
I commend the Clinton Health Access Initiative (CHAI) for financial assistance
to the Zambia National Formulary Committee for developing and producing
these Standard Treatment Guidelines as an educational strategy for managing
the common conditions afflicting the Zambian people. As usual, the book has
been improved to make it more user-friendly, pocket-size, with information on
disease conditions Descriptions, diagnoses and on how to develop therapeutic
interventions. The Committee upheld the original intent of making the
document a reference material for all health care providers, particularly medical
doctors, pharmacists, dentists, nurses, clinical officers and all those with
primary responsibility for prescribing, dispensing and administration of
medicines.
The first edition proved to be a very popular reference document to clinical
students and other health care workers contracted to provide health services in
Zambia. This book is designed to augment that erstwhile intent. I recommend
that you read and use the information herein to serve better those most in need.
Whether you work at the University Teaching Hospital, Mpulungu, Lukulu,
Monze, Chama or Chinyama Litapi, the information will help you provide good
quality, safe, effective and affordable health care.
Dr Kennedy Malama
Permanent Secretary - Technical Services
MINISTRY OF HEALTH
iii
Table of Contents
RECOMMENDED CITATION .......................................................................................................ii
FOREWORD .................................................................................................................................iii
ACKNOWLEDGMENTS .............................................................................................................. xii
INTRODUCTION ......................................................................................................................... 15
ARRANGEMENT OF INFORMATION ........................................................................................ 16
1.
GASTRO-INTESTINAL CONDITIONS............................................................................ 19
1.1.
ABDOMINAL PAIN ......................................................................................................... 19
1.1.1. Gastritis ............................................................................................................................ 19
1.1.2. Chronic Peptic Ulcer Disease .............................................................................................. 19
1.2.
DIARRHOEA ................................................................................................................... 22
1.2.1. Acute diarrhoea ................................................................................................................. 22
1.2.2. Acute diarrhoea in children ................................................................................................ 22
1.2.3. diarrhoea in adults ............................................................................................................. 23
1.2.4. Chronic/Persistent Diarrhoea .............................................................................................. 24
1.3.
DYSENTERY ................................................................................................................... 26
1.3.1. Bacillary Dysentery ............................................................................................................ 26
1.3.2. Amoebic Dysentery ............................................................................................................. 28
1.4.
CHOLERA ....................................................................................................................... 30
1.5.
HELMINTH INFESTATION ............................................................................................ 34
1.5.1. Nematodes......................................................................................................................... 34
1.5.2. Cestodes or Tapeworms ...................................................................................................... 37
1.5.3. Trematodes or Flukes ......................................................................................................... 38
1.6.
GIARDIASIS .................................................................................................................... 39
2.
CENTRAL NERVOUS SYSTEM CONDITIONS ............................................................... 40
2.1.
MENTAL HEALTH AND PSYCHIATRIC ILLNESSES ................................................... 40
2.1.1. Anxiety Disorders............................................................................................................... 40
2.1.2. Obsessive-Compulsive Disorder ........................................................................................... 43
2.1.3. Social Anxiety Disorder ...................................................................................................... 45
2.1.4. Post-Traumatic Stress Disorders.......................................................................................... 46
2.1.5. Panic Attack Disorder ........................................................................................................ 48
2.2.
MOOD DISORDERS ........................................................................................................ 51
2.2.1. Bipolar Mood Disorders...................................................................................................... 51
2.2.2. Depressive Disorders .......................................................................................................... 53
2.3.
PSYCHOTIC DISORDERS .............................................................................................. 56
2.3.1. Brief Psychotic Disorder ..................................................................................................... 56
2.2.3. Schizophrenia .................................................................................................................... 57
2.4.
EPILEPSY........................................................................................................................ 59
2.5.
FEBRILE CONVULSIONS ............................................................................................... 60
iv
2.6.
3.
3.1.
3.1.1.
3.1.2.
3.1.3.
3.2.
3.2.1.
3.2.2.
3.2.3.
3.2.4.
3.2.5.
3.2.6.
3.2.7.
3.2.8.
3.2.9.
3.2.10.
3.2.11.
3.2.12.
3.2.13.
3.3.
3.3.1.
3.3.2.
3.4.
3.5.
3.5.1.
3.5.2.
3.5.3.
3.5.4.
3.5.5.
3.5.6.
3.5.7.
3.5.8.
3.5.9.
3.5.10.
3.5.11.
3.5.12.
3.5.14.
3.5.15.
3.5.16.
3.6.
3.6.1.
RABIES............................................................................................................................ 66
INFECTIONS ................................................................................................................... 68
MALARIA ....................................................................................................................... 68
Uncomplicated Malaria ...................................................................................................... 68
Severe Malaria ................................................................................................................. 69
Malaria in Pregnancy ......................................................................................................... 74
TUBERCULOSIS ............................................................................................................ 77
Pulmonary Tuberculosis ...................................................................................................... 77
Pleural tuberculosis ............................................................................................................. 77
Pericardial tuberculosis ........................................................................................................ 78
Lymph node tuberculosis ...................................................................................................... 78
Meningeal tuberculosis ........................................................................................................ 78
Bone tuberculosis ................................................................................................................ 78
Gastrointestinal tuberculosis ................................................................................................. 78
Genito-urinary tuberculosis .................................................................................................. 78
Dermal tuberculosis ............................................................................................................. 78
Adrenal tuberculosis ............................................................................................................ 78
Multidrug-resistant Tuberculosis (MDR-TB) ............................................................................... 82
Extensively Drug-Resistant Tuberculosis (XDR-TB) ................................................................. 83
Tuberculosis and Immunocompromised Patients ...................................................................... 83
MENINGITIS ................................................................................................................... 84
Bacterial Meningitis ............................................................................................................ 86
Fungal Meningitis ............................................................................................................... 88
ANTHRAX ....................................................................................................................... 89
SEXUALLY TRANSMITTED INFECTIONS (STI) .......................................................... 90
Gonococcal urethritis ....................................................................................................... 91
Non-Gonococcal Urethritis ............................................................................................... 92
Gonorrhoea in Neonates ................................................................................................... 94
Pelvic Inflammatory Disease ............................................................................................... 95
Vulvovaginitis ................................................................................................................... 96
Urinary Tract Infection .................................................................................................... 98
Syphilis............................................................................................................................. 98
Chancroid ...................................................................................................................... 100
Lymphogranuloma Venereum ......................................................................................... 100
Herpes Genitalis ............................................................................................................. 101
Granuloma lnguinale (Donovanosis)............................................................................... 104
Genital Growth (Condylomata Acuminata) ...................................................................... 105
Acute Epididymo-orchitis ................................................................................................ 108
Urinary Tract Infection ................................................................................................... 109
Acute Pyelonephritis ....................................................................................................... 111
THE PLAGUE ................................................................................................................. 112
Bubonic Plague .............................................................................................................. 112
v
Primary Pneumonic Plague ............................................................................................ 113
HUMAN IMMUNODEFICIENCY VIRUS (HIV) AND ACQUIRED IMMUNE DEFICIENCY SYNDROME
(AIDS) ............................................................................................................................. 114
3.7.1. Pre-Exposure Prophylaxis (PrEP) ..................................................................................... 118
3.7.2. Post-Exposure Prophylaxis of HIV (PEP) .......................................................................... 122
3.7.3. Non-Occupational Post-Exposure Prophylaxis (nPEP)............................................................ 124
3.7.4. HIV-2 Treatment ............................................................................................................ 126
3.7.5. Elimination of Mother-to-Child HIV Transmission (EMTCT) ......................................... 133
3.7.6. Non-Mother-to-Child (horizontal) Transmission .................................................................... 134
3.7.7. Post-Exposure Prophylaxis for Sexually Assaulted Child ................................................. 134
3.7.8. Management of Patients Previously on ART .................................................................... 135
3.7.9. Management of Pregnant and Breastfeeding Women defaulters or Failing Therapy ........ 135
3.7.10. Treatment Failure with No Further Treatment Options ................................................... 136
3.7.11. Immune Reconstitution Inflammatory Syndrome (IRIS) and HIV ................................... 139
4.
DISEASES AND CONDITIONS AFFECTING ENDOCRINE SYSTEM .......................... 140
4.1.
DIABETES MELLITUS.................................................................................................. 140
4.1.1. Type 1 Diabetes mellitus ................................................................................................... 141
4.1.2. Type 2 Diabetes Mellitus (T2DM) ...................................................................................... 142
4.1.3. Hyperglycaemic/Ketoacidosis Coma/Precoma ..................................................................... 145
4.1.4. Hypoglycaemia in Diabetes Mellitus .................................................................................. 147
4.1.5. Diabetes Mellitus in Pregnancy ......................................................................................... 149
5.
OBSTETRIC AND GYNAECOLOGICAL CONDITIONS ............................................... 150
5.1.
ANTENATAL CARE ...................................................................................................... 150
5.2.
NORMAL LABOUR ....................................................................................................... 151
5.3.
ANTEPARTUM HAEMORRHAGE (APH) ..................................................................... 153
5.3.1. Placenta previa ................................................................................................................ 153
5.3.2. Abruptio placentae ........................................................................................................... 154
5.3.3. Cervical lesion ................................................................................................................. 155
5.3.4. Vasa Previa ..................................................................................................................... 155
5.4.
POSTPARTUM HAEMORRHAGE (PPH) ...................................................................... 156
5.5.
UNCONSCIOUS OBSTETRIC PATIENT ....................................................................... 158
5.6.
PRE-ECLAMPSIA AND ECLAMPSIA ........................................................................... 159
5.6.1. Mild pre-eclampsia ........................................................................................................... 159
5.6.2. Severe pre-eclampsia ........................................................................................................ 159
5.6.3. Eclampsia ....................................................................................................................... 159
5.6.4. Pre-eclampsia management in outpatients .......................................................................... 159
5.6.5. Mild pre-eclampsia and gestation less than 37 weeks ........................................................... 160
5.6.6. Severe pre-eclampsia and eclampsia .................................................................................. 160
5.6.7. Pre-eclampsia and eclampsia in labour .............................................................................. 162
5.6.8. Care for the neonate ......................................................................................................... 163
5.7.
MEDICAL DISEASES IN PREGNANCY ........................................................................ 163
5.7.1. Diabetic Mellitus .............................................................................................................. 163
3.6.2.
3.7.
vi
5.7.2. Cardiac diseases............................................................................................................... 164
5.7.3. Malaria in Pregnancy ....................................................................................................... 165
5.7.4. Elimination of Mother-to-Child Transmission of HIV (EMTCT) .......................................... 166
5.8.
ABORTION .................................................................................................................... 169
5.9.
MEDICAL ABORTION (TERMINATION OF PREGNANCY) ........................................ 170
5.9.1. Uterine Evacuation Procedures ......................................................................................... 172
5.9.2. Post-abortion care (PAC) .................................................................................................. 175
5.10.
MENSTRUAL DISORDERS .......................................................................................... 176
5.10.1. Dysmenorrhea ................................................................................................................ 176
5.10.2. Amenorrhoea .................................................................................................................. 177
5.10.3. Oligomenorrhoea ............................................................................................................. 178
5.10.4. Polymenorrhoea .............................................................................................................. 178
5.10.5. Meno-metrorrhagia .......................................................................................................... 178
5.10.6. Post-menopausal bleeding................................................................................................. 178
6.
RESPIRATORY TRACT DISEASES .............................................................................. 180
6.1.
RESPIRATORY TRACT INFECTIONS ......................................................................... 180
6.1.1. Upper Respiratory Tract Infections .................................................................................... 180
6.2.
LOWER OBSTRUCTIVE AIRWAY DISEASES ............................................................. 190
6.2.1. Asthma............................................................................................................................ 190
6.2.2. Emphysema ..................................................................................................................... 193
7.
CARDIOVASCULAR DISORDERS................................................................................ 195
7.1.
HYPERTENSION........................................................................................................... 195
7.1.1. Primary Hypertension ...................................................................................................... 196
7.1.2. Secondary Hypertension ................................................................................................... 196
7.1.3. Systolic Hypertension ....................................................................................................... 197
7.1.4. Hypertensive Crises .......................................................................................................... 197
7.2.
CONGESTIVE HEART FAILURE ................................................................................. 200
7.2.1. Cardiogenic shock ............................................................................................................ 203
7.2.2. Dilated Cardiomyopathy ................................................................................................... 204
7.3.
MYOCARDIAL INFARCTION ...................................................................................... 207
7.4.
ANGINA PECTORIS ...................................................................................................... 209
7.5.
PULMONARY OEDEMA ............................................................................................... 210
7.6.
RHEUMATIC FEVER .................................................................................................... 211
7.7.
CARDIAC ARRHYTHMIAS .......................................................................................... 213
7.8.
INFECTIVE ENDOCARDITIS ....................................................................................... 216
7.9. CARDIOPULMONARY RESUSCITATION AND ADVANCED CARDIAC LIFE SUPPORT 219
7.9.1. Basic life support (BLS) .................................................................................................... 219
7.9.2. Advanced cardiac life support............................................................................................ 220
8.
MALIGNANCIES........................................................................................................... 222
8.1.
LEUKAEMIAS ............................................................................................................... 222
8.1.1. Acute Lymphoblastic Leukaemia (ALL) ............................................................................. 222
8.1.2. Acute Myelogenous Leukaemia ......................................................................................... 224
vii
8.1.3.
8.1.4.
8.2.
8.2.1.
8.2.2.
8.2.3.
8.3.
8.4.
8.5.
8.6.
8.7.
8.8.
8.9.
8.10.
8.11.
8.11.1.
8.11.2.
8.11.3.
8.11.4.
8.12.
8.13.
8.14.
8.15.
8.16.
8.17.
8.18.
8.19.
8.20.
8.21.
8.22.
8.22.1.
8.22.2.
8.22.3.
8.22.4
9.
9.1.
9.1.1.
9.1.2.
9.2.
9.3.
9.3.1.
9.3.2.
Chronic Lymphatic Leukaemia (CLL)................................................................................ 225
Chronic Myeloid Leukaemia (CML) .................................................................................. 227
LYMPHOMAS ............................................................................................................... 229
Hodgkin's Disease (HD) ................................................................................................... 229
Non-Hodgkin's Lymphoma ............................................................................................... 230
Burkitt’s Lymphoma......................................................................................................... 232
CARCINOMA OF THE BREAST ................................................................................... 233
CERVICAL CANCER .................................................................................................... 235
OVARIAN CANCER ...................................................................................................... 236
ENDOMETRIAL CANCER ............................................................................................ 238
PROSTATE CANCER .................................................................................................... 238
TESTICULAR TUMOURS ............................................................................................. 240
VULVAL CANCER ........................................................................................................ 242
PENILE CANCER .......................................................................................................... 244
NON-MELANOMA SKIN CANCER ............................................................................... 244
Squamous Cell Carcinoma of the skin ................................................................................ 244
Basal cell carcinoma ........................................................................................................ 245
Melanoma ....................................................................................................................... 246
Kaposi's sarcoma ............................................................................................................. 247
OESOPHAGEAL CARCINOMA .................................................................................... 248
COLORECTAL CARCINOMA ...................................................................................... 249
GASTRIC CANCER ....................................................................................................... 250
PANCREATIC CANCER................................................................................................ 252
ANAL CANCER ............................................................................................................. 253
ASTROCYTOMAS ......................................................................................................... 254
LUNG CANCER ............................................................................................................. 255
NASOPHARYNGEAL CARCINOMA ............................................................................. 257
OTHER HEAD AND NECK CANCER ............................................................................ 258
THYROID CANCER ...................................................................................................... 259
PAEDIATRIC CANCER ................................................................................................. 260
Medulloblastoma.............................................................................................................. 261
Retinoblastoma ................................................................................................................ 262
Nephroblastoma (Wilms' Tumour)..................................................................................... 269
Rhabdomyosarcoma ......................................................................................................... 274
EYE DISEASES.............................................................................................................. 277
THE RED EYE ............................................................................................................... 277
With Pain ........................................................................................................................ 277
Without Pain ................................................................................................................... 284
TRACHOMA ................................................................................................................. 286
LUMPS AND BUMPS ON AND AROUND THE EYEBALL ............................................ 287
Stye ................................................................................................................................. 288
Tarsal Cyst (Chalazion)..................................................................................................... 288
viii
9.3.3.
9.3.4.
9.3.5.
9.3.6.
9.4.
9.4.1.
9.4.2.
9.4.3.
9.5.
9.5.1.
9.5.2.
9.6.
9.7.
9.8.
9.8.1.
9.8.2.
9.9.
9.9.1.
9.9.2.
9.9.3.
10.
10.1.
10.1.1.
10.2.
10.3.
10.3.1.
10.3.2.
10.3.3.
10.3.4.
10.4.
11.
11.1.
11.1.2.
11.1.3.
11.1.4.
11.2.
11.2.2.
11.2.3.
11.2.4.
11.3.
11.3.1.
Orbital Dermoid Cyst........................................................................................................ 289
Pinguicula ....................................................................................................................... 289
Pterygium ........................................................................................................................ 289
Malignant........................................................................................................................ 291
COMMON EYE DISEASES ASSOCIATED WITH HIV/AIDS ........................................ 292
Moluscum Contangiosum ................................................................................................. 292
Herpes Zoster Ophthalmicus ............................................................................................. 293
Cytomegalovirus Retinitis (CMV) ...................................................................................... 294
OPTICS & REFRACTION (REFRACTIVE ERRORS AND LOW VISION) .................... 295
Refractive Errors ............................................................................................................. 295
Low Vision (VA range of 6/18 – 6/60) ................................................................................ 296
STRABISMUS (SQUINT) ............................................................................................... 296
SYSTEMIC EYE DISEASES AND THE EYE.................................................................. 299
OCULAR EMERGENCIES ............................................................................................ 304
Absolute Emergencies ...................................................................................................... 304
Relative Emergencies ....................................................................................................... 306
GLAUCOMA ................................................................................................................. 306
Primary angle closure (congestive) Glaucoma .................................................................... 306
Primary open-angle glaucoma........................................................................................... 306
Primary Congenital Glaucoma .......................................................................................... 308
ANAEMIA AND NUTRITIONAL ................................................................................... 310
CONDITIONS ................................................................................................................ 310
ANAEMIA ..................................................................................................................... 310
Treatment of nutritional anaemia ..................................................................................... 312
MALNUTRITION.......................................................................................................... 313
VITAMIN DEFICIENCIES ............................................................................................ 317
Vitamin A ....................................................................................................................... 317
Vitamin B group .............................................................................................................. 318
Vitamin C (Ascorbic acid) ................................................................................................. 318
Vitamin D........................................................................................................................ 319
VULNERABLE GROUP FEEDING ................................................................................ 320
DERMATOLOGICAL CONDITIONS ............................................................................ 321
BACTERIAL INFECTIONS ........................................................................................... 321
Abscess ........................................................................................................................... 321
Impetigo .......................................................................................................................... 322
Eczema ........................................................................................................................... 323
FUNGAL INFECTIONS ................................................................................................. 324
Tinea corporis (ringworm of body, trunk and limbs) ............................................................ 326
Tinea capitis (scalp ringworm) .......................................................................................... 326
Cutaneous Candidiasis ..................................................................................................... 327
VIRAL SKIN INFECTIONS ........................................................................................... 328
Chickenpox ..................................................................................................................... 328
ix
11.3.2.
11.3.3.
11.4.
11.4.1.
11.4.2.
12.
12.1.
12.1.1.
12.1.2.
12.1.3.
12.1.4.
12.1.5.
12.2.
12.2.1.
12.2.2.
12.2.3.
12.3.
12.3.1.
12.3.2.
12.4.
12.4.1.
12.4.2.
13.
13.1.
13.1.1.
13.1.2.
13.1.3.
13.2.
13.3.
13.4.
13.5
13.6.
13.7.
13.8.
14.
14.1.
14.2.
14.2.1.
14.2.2.
14.2.3.
14.2.4.
14.2.5.
Herpes Zoster ................................................................................................................. 328
Herpes Simplex ............................................................................................................... 329
PARASITIC INFESTATIONS ........................................................................................ 329
Pediculosis (lice) ............................................................................................................. 329
Scabies ........................................................................................................................... 330
CONDITIONS OF THE EAR, NOSE AND OROPHARYNX ........................................... 332
ORAL DISEASES .......................................................................................................... 332
Dental caries................................................................................................................... 332
Periodontal disease .......................................................................................................... 333
Oral candidiasis .............................................................................................................. 335
Herpes simplex stomatitis ................................................................................................. 335
Mouth Ulcers .................................................................................................................. 336
PHARYNGEAL DISEASES ........................................................................................... 337
Tonsillitis and Pharyngitis ............................................................................................... 337
Peri-tonsillar abscess ....................................................................................................... 338
Epiglottitis ...................................................................................................................... 340
NASAL DISEASES ........................................................................................................ 340
Acute sinusitis ................................................................................................................. 340
Allergic rhinitis ............................................................................................................... 341
EAR CONDITIONS ....................................................................................................... 342
Acute otitis media ............................................................................................................ 342
Chronic suppurative otitis media ....................................................................................... 343
SURGICAL CONDITIONS ............................................................................................ 344
INJURIES...................................................................................................................... 344
Minor injuries ................................................................................................................. 344
Major injuries ................................................................................................................. 345
Specific injuries .............................................................................................................. 346
BITES............................................................................................................................ 353
TESTICULAR TORSION .............................................................................................. 354
STRANGULATED HERNIA .......................................................................................... 355
HYDROCELE ............................................................................................................... 356
VARICOCELE .............................................................................................................. 356
TESTICULAR TUMOURS .......................................................................................... 357
ACUTE MUMPS ORCHITIS ...................................................................................... 358
POISONING ................................................................................................................. 359
MANAGEMENT OF A POISONED PATIENT .............................................................. 359
TREATMENT OF SPECIFIC COMMON POISONING ................................................ 361
Aspirin and other Salicylates .......................................................................................... 361
Carbon monoxide .......................................................................................................... 361
Ethanol......................................................................................................................... 361
Insecticides ................................................................................................................... 361
Paraffin, petrol and other petroleum products .................................................................. 362
x
14.2.6.
14.2.7.
14.2.8.
14.2.9.
15.
15.1.
15.1.1.
15.1.2.
15.1.3.
15.1.4.
15.1.5.
15.4.
15.5.
15.5.1.
15.5.2.
15.5.3.
15.5.4.
15.5.
15.5.1.
15.5.2.
15.6.
15.6.1.
15.6.2.
15.6.4.
15.6.5.
16.
Paracetamol poisoning ................................................................................................. 362
Chloroquine poisoning .................................................................................................. 363
Mushroom or other food poisoning................................................................................. 363
Snake Bites .................................................................................................................. 363
DISORDERS OF THE RENAL SYSTEM .................................................................... 365
METABOLIC DISORDERS ........................................................................................ 365
Hyperkalemia ............................................................................................................... 365
Hypokalemia ................................................................................................................ 366
Hypernatremia ............................................................................................................. 367
Hyponatremia............................................................................................................... 368
Hypercalcaemia............................................................................................................. 369
CATHETER-RELATED BLOODSTREAM INFECTIONS (CRBSI) ............................. 370
GLOMERULAR DISORDERS ..................................................................................... 371
Nephrotic syndrome ....................................................................................................... 371
Nephritic syndrome........................................................................................................ 378
Asymptomatic hematuria/proteinuria .............................................................................. 380
Rapid Progressive Glomerulonephritis............................................................................. 380
HYPERTENSION ........................................................................................................ 381
Malignant hypertension ................................................................................................. 381
Hypertension or kidney disease in pregnancy ................................................................... 382
RENAL AND PANCREATIC TRANSPLANT ............................................................... 385
Criteria for Renal or/and Pancreatic Transplant .............................................................. 385
Immunosuppression in Live-donor Kidney Transplant patients ....................................... 388
Immunosuppression protocols ........................................................................................ 388
Fertility and Pregnancy post-transplant ........................................................................... 389
MEDICINE SAFETY MONITORING (PHARMACOVIGILANCE) .............................. 390
ZAMBIA ESSENTIAL MEDICINE LIST (ZEML) ........................................................ 392
ESSENTIAL LABORATORY SUPPLIES LIST ............................................................ 426
xi
ACKNOWLEDGMENTS
The Zambia National Formulary Committee is grateful to the Ministry of Health
for the support given to review and produce the fourth edition of the Standard
Treatment Guidelines, Essential Medicines List, and Essential Laboratory
Supplies for Zambia. The committee is indebted to the United Nations Population
Fund (UNFPA) and the Clinton Health Access Initiative (CHAI) for the technical
and financial support towards the development and printing of this book.
The fourth edition has a number of chapters re-edited and revised as necessary.
The new sections on Malaria in pregnancy, elimination of mother to child
transmission of HIV have been added.
Management of infectious diseases requires the rational use of antimicrobials to
preserve their effectiveness. Drug-resistant microbes causing public health
diseases such as TB, Malaria, and HIV/AIDS now threaten successful treatment
of infectious diseases. Health gains achieved by priority health programs including tuberculosis (TB), malaria, acute respiratory infections (ARI), diarrheal
diseases, sexually transmitted infections (STIs) and HIV/AIDS - are increasingly
threatened by the growing worldwide problem of antimicrobial resistance
(AMR). If we do not preserve our heritage of current antimicrobials, in a few
years we are going to have hospitals filled with patients with resistant infections.
The credit of shaping this document into its present form is shared by many
individuals. We thank the untiring efforts and commitment provided by the
Committee members and those co-opted to contribute. This book was written by
a multi-disciplinary interdependent team of reviewers and editors who worked
together on all aspects of reviewing, writing, editing and producing the book.
Each member brought a wealth of knowledge, talent and experience in health
care. Together the committee members met several times and at different venues,
critically analyzed the revisions and shared their experiences with evidence to
produce this document with a power to improve the alleviation, provide relief to
ailments and care of the people.
We also thank individuals and groups of professionals who offered a constructive
critique of the previous edition that enabled improvements on this document.
xii
Zambia National Formulary Committee 2017 - 2020
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
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22.
Dr KOR Chiyeñu - Consultant Physician, Livingstone Central Hosiptal
(Chairperson)
Mr Oliver Hazemba - Senior Technical Advisor, Management Sciences for
Health (Vice-Chairperson)
Dr Owen Ngalamika - Dermatologist, University Teaching Hospital
Mr Pious Hachizo - Senior Pharmacist, Cancer Diseases Hospital
Dr Maureen Chisembele – Obstetrician/Gynecologist; Senior Medical
Superintendent, University Teaching Hospital - Women and Newborn
Hospital
Mrs Ilitongo Saasa Sondashi – Director Logistics, Medical Stores Limited
Mr Maxwell Kasonde - Public Health Pharmacist, Ministry of Health
Mr Billy Mweetwa - National Programme Officer, GHSC-PSM
Dr Sally Trollip – Physician, University Teaching Hospital
Mr Enock Chikatula – Chief Pharmacist, Levy Mwanawasa University
Teaching Hospital
Dr Pauline Musukwa Sambo - Oncologist, University Teaching Hospital
Mr Emmanuel Mubanga – Assistant Director Pharmaceutical Services,
Ministry of Health
Mr Boyd Mwanashimbala – Chief Pharmacist, Rational Drug Use, Ministry
of Health
Mr Luke Alutuli – Chief Pharmacist, University Teaching Hospital
Dr Kennedy Lishimpi - Director Clinical Care and Diagnostics Services,
Ministry of Health
Mr Abraham Mukesela – Chief Pharmacist, Lusaka Province
Dr Mweemba Aggrey – Nephrologist, University Teaching Hospital
Dr Gloria Munthali – Paediatrics HIV Coordinator, Ministry of Health
Dr Susan Citonje Musadabwe - Senior Medical Superintendent, Cancer
Diseases Hospital
Dr Francis Simenda – Consultant, Chainama Hills Hospital
Ms Anne Zulu – Director, Pharmaceutical Standards, Medical Stores Limited
Mr Chikuta Mbewe – Managing Director, Medical Stores Limited.
Other Technical Reviewers
1. Mr Chimuka Hampango - Reproductive Health Commodity Security
Programme Analyst, United Nations Population Fund
2. Dr Angel Mwiche – Ass. Director, Ministry of Health
3. Mr Waza Bright Mhango – Program Manager, Clinton Health Access
Initiative
4. Mr. Emmanuel Mubanga – Ass director, Phamaceutical Services, Ministry of
Health
xiii
5. Dr Chichonyi A. Kalungia – Lecturer, University of Zambia
6. Dr Chiluba Mwila – Head, Department of Pharmacy, Universtity of Zambia
7. Dr Jimmy Hangoma – Lecturer, Levy Mwanawasa Medical University
8. Ms Ellah Zingani – Lecturer, University of Zambia
9. Dr Chileshe – Cardiologist, University Teaching Hospital.
10. Mr Peter Lukonde – HIV Pharmacist, Ministry of Health
11. Mr Morton Kunga – Chief TB Officer, Ministry of Health
12. Mr Mathews Mwale – Chief Pharmacist, Copperbelt Province
13. Dr Justor Banda – Renal Consultant, Clinical Care Specialist, Copperbelt
Province
14. Mr Keegan Mwape – Chief Pahrmacist, Northern Province
15. Mr Malama Malema – Chief Pharmacist, Muchinga Province
16. Chibosha Kandandu – Chief Pharmacist, Central Province
Design and print: Mobrin Colour Drop
Secretariat
1. Mr Maxwell Kasonde – Public Health Pharmacist, Ministry of Health
2. Mrs Ilitongo Saasa Sondashi – Director Logistics, Medical Stores Limited
3. Mr Boyd Mwanashimbala – Chief Pharmacist - Rational Drug Use, Ministry
of Health
4. Dr Richard Nsakanya – Ministry of Health
5. Dr Daniel Makawa – Department of Clinical Care and Diagnostics Services,
Ministry of Health
6. Mr Nyambe Sitali - Office Assistant
xiv
INTRODUCTION
The Standard Treatment Guidelines were developed after wide consultations
and discussions with healthcare providers at three tires of the health delivery
system – practitioners, program managers and health economists. While
most of the key information has been retained, extensive revisions were
carried out on some of the chapters such as HIV and AIDS, psychiatric
conditions, STI, and eye conditions. While some of the changes to treatment
strategies were motivated by the dynamism of the conditions and availability
of more effective medicines and conformity with national disease-specific
guidelines, some of them were influenced by the new treatment strategies as
guided by the World Health Organization and evidence from clinical studies.
Antiretroviral therapy of HIV infections in adults, adolescence, infants and
children were adopted from WHO guidelines as recommended for a public
health approach. The guidelines are based on a comparison between various
drug therapies and on consideration of value for money and the most
effective, affordable and current practices that produce health outcomes of
improved quality of life and alleviation of suffering. They are also based on
the essential drugs and medical supplies concepts to meet the basic health
needs of the Zambians as close to the family as possible as envisioned by the
National Drug Policy.
The essential medicines and laboratory supplies listed in the Essential
Medicines and Essential Laboratory Supplies Lists are linked to the standard
treatment guidelines as indicative of public health priorities for the
pharmaceutical systems. The lists are based on national clinical choices that
the Government of the Republic of Zambia makes available and accessible to
its citizens at all times. The medicines and supplies selection was also based
on sound and adequate information of efficacy from clinical settings,
evidence of performance from different health care settings, availability in a
form in which quality, stability in the Zambian weather and storage settings,
bioavailability and users are assured. In addition, the total cost of treatment
and methodology of administration were also considered.
The Medicines and Therapeutic Committees and hospital and district health
management teams are mandated to use these Guidelines and Lists as
management tools to improve the quality of the health care delivery and meet
the public health responsibility of transparency and accountability. Individual
15
health care professionals are encouraged to use the guidelines as a companion
in the course of health care delivery provision.
ARRANGEMENT OF INFORMATION
The guideline text divisions into chapters according to a particular system of
the body or an aspect of medical care has been retained.
Chapters are divided into sections providing introductory notes for health
care providers who include doctors, pharmacists, nurses and other health
professionals. This information is intended to assist with decision making
and selection of appropriate treatment.
Descriptive information about the disease or condition is outlined in the
following manner:
•
•
•
•
•
Description of disease or condition
Clinical features
Diagnosis
Complications
Treatment
– Supportive
– Drugs
• Prevention
MEDICINE SAFETY MONITORING (PHARMACOVIGILANCE)
This chapter provides guidance about pharmacovigilance practice required
by all users of medicines and the actions to take to report medication safety
concerns in general.
ZAMBIA ESSENTIAL MEDICINES LIST
This list contains an appropriate range of essential medicines for the various
levels of health care delivery institutions in the country.
ESSENTIAL LABORATORY SUPPLIES AND REAGENTS
This list contains the most essential laboratory supplies and reagents for
laboratory use.
INDEXES
16
Indexes have been included listing the drugs in alphabetical order by
approved name or INN, and the diseases and conditions dealt with in the
guidelines.
PRESCRIBER CONTROL AND DRUG AVAILABILITY
No prescriber categories are provided in the text of this edition. Medicines
and Therapeutics Committees are expected to:
i. Control the prescribing practices of respective institutions.
ii. actively define policies for prescribing within a hospital, health
centre, clinic or district.
iii. Ensure the range of availability of drugs in any institution should be
restricted according to the level of institution and the categories of
staff prescribing.
Prescribers are advised to follow rational prescribing practices, outlined in
these standard treatment guidelines which emphasise the public priority use
of essential medicines and laboratory supplies and economic treatment
regimes.
17
REVISION OF STANDARD TREATMENT GUIDELINES CONTENTS
The Zambia National Formulary Committee recognises the fact that the field
of treatment regimens and drugs is dynamic, thus a revision of the guideline
contents will be continuous. Contributions are encouraged and should be
submitted for consideration to the Zambia National Formulary Committee
through the Ministry of Health.
Dr KOR Chiyeñu
Chairperson, Zambia National Formulary Committee
18
1. GASTRO-INTESTINAL CONDITIONS
1.1. ABDOMINAL PAIN
Abdominal pains include gastritis and peptic ulcer disease
1.1.1.
Gastritis
Description
This is divided into acute and chronic gastritis. In acute gastritis, there is
inflammation of the superficial gastric mucosa. It can occur as a result of
ingestion of drugs such as acetyl salicylic acid and other non-steroidal antiinflammatory drugs (NSAID) and alcohol.
Chronic gastritis is divided into 3 categories:
• Type A (autoimmune) gastritis seen in pernicious anaemia and also in
other autoimmune diseases.
• Type B (bacterial) gastritis, which is associated with Helicobacter pylori.
• Type C (chemical) gastritis, which is due to repeated injury with bile
reflux or chronic ingestion of NSAIDs.
Clinical features:
• Indigestion
• Vomiting
• Gastrointestinal haemorrhage
• Epigastric pain
Most chronic gastritis is asymptomatic.
Diagnosis:
• Endoscopy
Treatment
• Remove offending cause.
1.1.2. Chronic Peptic Ulcer Disease
Description:
Most peptic ulcers occur in the stomach or proximal duodenum but can also
occur in the oesophagus (with oesophageal reflux).
19
Clinical features:
• Epigastric pain
• Indigestion
• Flatulence
• Heartburn
• Anorexia; weight loss may occur
Diagnosis:
• Endoscopy
• Barium meal
Many patients, particularly the young presenting with indigestion, can be
treated symptomatically for 4-5 weeks without investigation.
Complications:
• Change of the oesophageal mucosa (Barrettes oesophagus) which is premalignant.
• Anaemia and frank haemorrhage
• Recurrent aspiration pneumonia when stricture formation is present
• Perforation of peptic ulcer
• Pyloric stenosis
Treatment:
Drugs
Antacids often relieve symptoms. They are best given when symptoms
occur or are expected usually between meals and at bedtime;
• Magnesium trisilicate compound chewable tablet 250 - 500mg to chew
when required or;
• Aluminium hydroxide chewable tablet 500mg - 1g to chew when
required
OR
• Magnesium trisilicate suspension 250mg with dried Aluminium
hydroxide 120mg 10ml orally 3 times daily OR
• Aluminium hydroxide (dried Aluminium hydroxide 500mg) 5 - 10ml
orally 4 times daily; Children 6 - 12 years 5ml orally 3 times daily;
• Adults 1 - 4 tablets to be chewed 4 times daily between meals and at
bedtime or as required.
20
Ulcer healing drugs
a) H2–receptor antagonists
Cimetidine 400mg tablets twice daily (with breakfast and at night) or
800mg at night for at least 4 weeks. Maintenance 400mg at night or
400mg morning and night.
Reflux oesophagitis:
• Cimetidine 400mg 4 times daily for 4 – 8 weeks.
• Ranitidine 150mg tablets twice daily (with breakfast and at night)
or 300mg at night for 4 – 8 weeks, up to 6 weeks in chronic
episodic dyspepsia. Maintenance 150mg at night.
• Ranitidine 150mg twice daily or 300mg at night for up to 8 weeks
or if necessary 12 weeks.
b)
Proton pump inhibitors
• Omeprazole 20mg tablets daily for 4 weeks followed by a further
4 – 8 weeks if not fully treated.
• Long term management of acid reflux disease. Omeprazole 10mg
daily increasing up to 20mg if symptoms return. Not
recommended for children.
c)
Tripotassium dicitratobismuthate (Bismuth chelate)
• Liquid 12mg/5ml. 10ml twice daily or 5ml 4 times daily for 28 days
followed by a further 28 days if necessary. Not recommended for
children.
• Tablets 120mg. 2 tablets twice daily or 1 tablet 4 times daily for 28
days followed by a further 28 days if necessary.
d)
Triple therapy regimens:
1-week regimen
•
Amoxycillin 500mg 3 times daily
Plus
•
Metronidazole 400mg 3 times daily
Plus
•
Omeprazole 20mg twice daily or 40mg once daily for 7 days
OR
•
Clarithromycin 500mg daily twice daily
Plus
•
Metronidazole 400mg (or Tinidazole 500mg) twice daily
Plus
Omeprazole 20mg twice daily or 40mg once daily for 7 days.
21
1.2. DIARRHOEA
Description
Diarrhoea is an increase in the frequency and volume of stools with an
alteration in the consistency, mainly due to increased water content. There
are two types of diarrhoea:
Acute Chronic
1.2.1. Acute diarrhoea
This is diarrhoea of sudden onset, often short-lived and is self-limiting. It
requires no investigation or treatment. It is often seen after dietary
indigestion. It may also be as a result of infections.
1.2.2. Acute diarrhoea in children
This is common of viral origin (e.g. Rotavirus, Norwalk virus, Adenoviruses
or Enterovirus), but may also be caused by bacteria or other parasitic
infections.
Clinical features:
In addition to diarrhoea, there may be fever, abdominal pain and vomiting. If
the diarrhoea is particularly severe, dehydration can be a problem.
With mild dehydration, there may be no signs. With moderate dehydration,
the child may present with the following:
• Irritability, restlessness Sunken eyes
• Dry mouth and tongue, absence of tears
• Thirst
• Skin pinch goes back slowly
With severe dehydration, the child may present with:
• Lethargy or loss of consciousness
• Absence of tears
• Very dry mouth and tongue
• Thirst associated with poor drinking
• Skin pinch that goes back very slowly
Treatment:
22
Investigations are necessary if diarrhoea has lasted more than 1 week. In the
meantime, supportive treatment should be given.
Stools should be sent for microscopy and culture; any infective causes should
be treated appropriately.
Fluid management - See section on Cholera.
In addition, the child should continue to feed on breast milk or other feeds.
Anti-diarrhoeal drugs are not recommended
Prevention:
•
•
•
•
•
Acute Provision of clean water/sanitation
Good disposal of faecal matter
Boiling drinking water
Chlorination of drinking water
Personal hygiene - handwashing preferably with soap and running water
after use of the toilet, when preparing food and before eating.
1.2.3. diarrhoea in adults
Clinical features:
In addition to diarrhoea, there may be fever, abdominal pain and vomiting.
Dehydration can also be a problem if the diarrhoea is severe. This may be
mild, moderate or severe in nature.
• Mild dehydration: The patient does not show enough signs to classify as
moderate or severe dehydration.
• Moderate dehydration: The patient has two or more of the following
signs:
– Restlessness
– Irritability
– Sunken eyes
– Dry mouth and tongue
– Absence of tears
– Thirsty, drinks eagerly
23
•
Severe dehydration: The patient is classified as having severe
dehydration if there are two or more of the following signs:
– Lethargic or unconscious; floppy
– Absence of tears
– Very dry mouth and tongue
– Very thirsty, drinks poorly or unable to drink
– Pinched skin goes back very slowly
Other signs in adults and children above 5 years are absent radial pulse and
low blood pressure.
Diagnosis:
Investigations are necessary if the diarrhoea lasts more than one week, i.e.,
stool microscopy, culture and drug susceptibility.
Treatment:
1. Fluid replacement
Fluid therapy (See the section on Cholera)
2.
Drug treatment
In chronic diarrhoea and HIV-related diarrhoea where the cause has not
been found:
•
Loperamide 2mg three times daily
•
Codeine phosphate 30mg four times daily
Any infective causes should be treated according to antimicrobial sensitivity
patterns.
Prevention:
As for acute diarrhoea in children
1.2.4.
Chronic/Persistent Diarrhoea
Description
This generally is diarrhoea lasting more than 2 weeks.
Causes include:
24
•
•
•
•
•
•
Infections such as giardia, cryptosporidium, lsospora belli and
microsporidia in AIDS patient.
Colonic lesions such as carcinoma, Crohn's disease and ulcerative
colitis
Coeliac disease, Tropical sprue, Chronic pancreatitis
Pseudo membranous colitis
Thyrotoxicosis
Diabetes
Clinical features:
Clinical features may include:
•
Diarrhoea, bloody diarrhoea or steatorrhoea Abdominal pain and
vomiting
•
Weight loss
•
Anaemia
Diagnosis Investigations:
•
Stool microscopy, culture and sensitivity
•
Special tests may be needed for certain parasites such as
cryptosporidium, isospora and microsporidia
•
Rectal/jejunal biopsy
•
Barium enema
•
Full blood count
Treatment:
Treat infective causes of chronic diarrhoea.
i.
Fluid therapy – Oral fluid use should be stressed except for patients
presenting with severe dehydration in whom intravenous fluids
should be used. However, even with severe dehydration, oral fluids
should be given concurrently. Fluid management is as for cholera
(See the section on Cholera).
ii.
Drug treatment - Antidiarrheal agents
•
•
•
Loperamide 2mg three times daily
Codeine phosphate 30mg four times daily
Nitazoxanide 100mg suspension;
Child 1 - 3 years 5ml twice a day with food for 3 days;
25
4 - 11 years 10ml twice a day with food for 3 days;
12 years and above, 500 mg tablets three times a day with food for 3
days.
Treat specific causes such as:
•
Giardia – Metronidazole 400mg 8 hourly orally for 7 days
•
Isospora Belli – Co-trimoxazole 960mg four times daily orally for 10
days. Give Pyrimethamine for sulpha-allergic patients. Recurrences
tend to occur.
•
Cryptosporidia – Albendazole 400mg twice daily orally for one
month may help although combination antiretroviral therapy (cART)
with immune reconstitution is the main line of management.
Prevention:
•
As for acute diarrhoea.
•
Prevention of HIV infection
1.3. DYSENTERY
Description
Dysentery is the passage of bloody diarrhoea or mucus or both in the stool.
There are two types of dysentery:
•
Bacillary
•
Amoebic
1.3.1. Bacillary Dysentery
Bacillary dysentery is caused by the bacteria Shigella which has a short
incubation period, usually being 2 days.
Clinical features:
•
Acute onset
•
Malaise
•
Fever
•
Watery diarrhoea
•
Bloody diarrhoea with mucus Faecal urgency
•
Severe cramping abdominal pain
26
•
•
•
•
•
•
Nausea
Vomiting
Headache
Convulsions (in children)
Tenesmus
Mild or moderate dehydration
Diagnosis:
•
Stool Microscopy may show leukocytes
•
Stool culture and susceptibility test
Treatment
Drugs:
•
The first drug of choice is Nalidixic Acid.
Adult: 1g orally 4 times a day for 7 days
Child: 50mg/ kg body weight orally in 4 divided doses for 7 days
OR
Ciprofloxacin - children 15mg/kg; adults 500mg twice daily for 3
days.
Use of Ciprofloxacin in children is contraindicated except where the benefit
outweighs the risk.
Complications of Shigella type 1 infection include:
•
Arthritis
•
Conjunctivitis
•
Colonic perforation
•
Septicaemia
•
Haemolytic uraemia syndrome
•
Metabolic disorders
•
Encephalopathy
•
Toxic megacolon and
•
Rectal prolapse in children
Prevention:
•
Drink clean, boiled/chlorinated water
•
Good sanitation
•
Good personal hygiene
27
1.3.2. Amoebic Dysentery
Description
Amoebic dysentery is caused by the parasite Entamoeba histolytica.
Clinical Features
• Bloody diarrhoea with mucus
• Low-grade fever
• Dehydration is unusual
Diagnosis
• Stool microscopy
• Sero diagnosis
Treatment
Drugs
• Metronidazole
Adult: 800mg orally 3 times daily for 5 days followed
by Diloxanide
furoate 500mg 3 times daily for 10 days (for the eradication of cysts)
Child: 1 – 3 years, 200mg orally 8 hourly for 5 days; 3 – 7 years, 200mg
orally 6 hourly for 5 days; 7 – 10 years, 400mg orally 8 hourly for 5 days
OR
• Tinidazole
Adult: 2g daily for 2 – 3 days.
Child: 50 – 60 mg/kg orally for 3 days.
Avoid the use of anti-diarrhoea agents
Supportive
• Fluid replacement – Refer to chapter 1.5
• Analgesics
Complications
• Fulminant colitis
• Colon perforation
• Peritonitis
• Chronic infection
28
•
•
•
•
Stricture formation
Severe haemorrhage
Amoebic liver abscess
Amoeboma
Prevention
• Good disposal of excreta - good pit latrines, flush toilets
• Provision of clean water
• Boiling water. This kills amoeba cysts if the water is boiled for at least
10 minutes.
• Chlorination of water - effects variable on an amoeba.
• Personal hygiene - washing of hands after use of the toilet, when
preparing food and before eating.
29
1.4. CHOLERA
Description
Cholera is an illness characterized by excessive diarrhoea and vomiting
caused by the organism Vibrio cholerae. It is transmitted by the faecal-oral
route.
Clinical features
The incubation period varies from a few hours to 6 days. Cholera may be
present as a mild illness indistinguishable from diarrhoea due to other causes.
Classically, however, it has three phases:
• Evacuation phase characterised by abrupt onset of painless, profuse
watery diarrhoea associated with vomiting in severe forms. Stools may
be rice-water.
• Collapse phase is reached if appropriate treatment is not given. This is
characterised by features of circulatory shock (cold clammy skin,
tachycardia, hypotension and peripheral cyanosis) and dehydration
(sunken eyes, hollow cheeks and diminished urine output. There may
also be muscle cramps.
Children may also have convulsions due to hypoglycaemia. Complications
such as renal failure and aspiration of vomitus may occur.
• Recovery phase occurs if the patient survives the collapse phase.
Diagnosis
• Largely clinical
• Stool and rectal swabs for culture
Treatment
1. Rehydration
Patients should be assessed for the degree of dehydration.
Management of mild dehydration
Give Oral Rehydration Salt (ORS) solution or any fluids after each loose
stool.
30
ORS Dose
Amount after each loose stool
Age
Less than
24 months
50 – 100ml after each loose stool
100 – 200ml
2 – 5 years
As much as the patient wants
10 years and above
ORS and other fluids should be continued until diarrhoea stops. Breastfed children should continue to breastfeed normally. Encourage the
patient to eat.
Management of moderate dehydration (some dehydration in children)
Give ORS in the first 4 hours as follows:
Age
Less
than 4
mnths
Weight Less than
5kg
Amount 150ml
in ml
per
(approx) hour
411
mnt
hs
510
kg
1223
mnt
hs
1012
kg
2459
mnt
hs
1219
kg
1629
kg
40
0
ml
pe
r
ho
ur
600
ml
pe
r
ho
ur
1,50
0ml
p
e
r
h
o
u
r
2,000
ml
p
e
r
h
o
u
r
31
514
yrs
15 yrs
and above
30kg and above
3,800ml
per hour
• Monitor the patient frequently
• Reassess the patient after 4 hours using the classification of
dehydration. If signs of (moderate) dehydration are still present,
repeat the same management. If the patient shows signs of severe
dehydration change management to that of severe dehydration.
• Patients should be encouraged to eat and drink as much as they want.
• If the child vomits, wait 10 minutes and then continue giving ORS
slowly, i.e. every 2 – 3 minutes.
• Encourage the mother to continue breastfeeding.
• For infants less than six months who are not breastfed also give 100
– 200ml clean water during this period.
Management of severe dehydration
Start intravenous drip with Ringers Lactate or Sodium Chloride 0.9% w/v
(normal saline) immediately (give ORS while drip is being set).
Patients below 1 year:
• Give 100ml/kg in 6 hours as follows:
30ml/kg in the first 1 hour then 70ml/kg in the next 5 hours.
Reassess the patient very frequently.
• If the patient can drink, give about 5ml/kg per hour of ORS in
addition to the IV fluid.
• Assess the state of re-hydration after six hours using the classification
of dehydration level chart; classify and manage accordingly.
• If the patient shows no sign of dehydration after treatment with IV
fluids or ORS, continue ORS as follows:
– Less than 24-months old
= 100ml after each loose stool
– 2 – 9 years-old
= 200ml after each loose stool
– 10 years or more
= as much as the patient wants (at least 300ml)
Patients 1 year and above:
• Give IV fluids, 100ml/kg in 3 hours as follows: 30ml/kg as rapidly
as possible (within 30 minutes), then
32
70ml/kg in the next 21/2 hours.
Reassess the patient very frequently.
• If the patient can drink, give about 5ml/kg per hour of ORS in
addition to the IV fluid.
• Assess the state of rehydration after 3 hours using the classification
of dehydration on treatment charts; reclassify and manage
accordingly.
• If the patients show no sign of dehydration after treatment with IV
fluids or ORS continue ORS as follows:
– 24 months old = 100ml after each loose stool
– 2 – 9 years old = 200ml after each loose stool
– More than 9 years = as much as the patient wants (at least 300ml)
Drugs
Medicines should only be given according to the sensitivity patterns.
Recommended Antibiotics
ANTIBIOTICS
CHILDREN
ADULTS
Doxycycline
One single dose
–
300mg
Tetracycline
4 times daily
for 3 days
(For children
>12 years)
12.5mg/kg
500mg
Erythromycin
Adults: 4 times
daily for 3 days
Children: 3 times
daily for 3 days
10mg/kg
250mg
33
• Doxycycline is WHO antibiotic of choice for adults (except pregnant
women) because only one dose is required.
• Erythromycin may be used when the other recommended antibiotics
are not available, or where V. cholerae is resistant to them.
Prevention
• Drink clean boiled/ chlorinated water
• Good sanitation
• Good personal hygiene and sanitation
1.5. HELMINTH INFESTATION
Description
Helminthic infestation is infection with worms, which belong to several
different classes, i.e. Nematodes, Cestodes and Trematode or flukes.
These affect various parts of the body such as the skin, muscles, lymphatics,
blood or gastrointestinal tract.
Trematodes or flukes will be presented under schistosomiasis.
1.5.1.
Nematodes
1.5.1.1. Non-intestinal
1.5.1.1.1. Filariasis
The adult worms are threadlike. The large females give birth to larvae known
as microfilaria. These require two hosts to complete their lifecycle. The first
host is the mosquito culex, aedes, anopheles or other types of flies such as
Simulium.
Clinical features
Wuchereria bancrofti
Adult worms are found in the lymphatics and lymph nodes. Larvae grow and
mature in the regional lymph nodes for up to 18 months. The patient then
presents with fever ranging 39° - 41°C accompanied by lymphangitis, both
of which subside in 3 - 5 days. The involved lymphatics appear as red streaks
on the skin, are tender and cord-like. The lymphatics of the epididymis, testes
34
and spermatic cord may be involved. The obstruction phase follows if
treatment is not given. This presents with oedema of the lower limbs and
scrota. Long-standing oedema produces thick rough skin which may
ulcerate.
Complications
Tropical eosinophilia is characterized by either lymphadenopathy,
splenomegaly or cough, bronchospasm and asthma-like picture.
Loa loa
Clinical features are caused by adult worms which prefer the
subconjunctival and periorbital tissues. The main features are Calabar
swellings – painless, localised, transient, hot soft tissue swellings often near
joints. They last from a few hours to several weeks. Urticaria, pruritis,
lymphoedema, arthritis and chorioretinitis may occur.
A
meningoencephalitis like picture may occur during treatment.
Onchocerciasis
The incubation period averages 1 year. Initially, a papular, reddish, itchy
rash occurs. After repeated infection subcutaneous nodules develop. The
nodules may be associated with genital elephantiasis, hydrocele and ocular
lesions. Ocular lesions are serious and may cause blindness. Initially, there
is excessive tear production, photophobia and the sensation of a foreign body
in the eye. Then conjunctivitis, iridocyclitis, chorioretinitis, secondary
glaucoma and optic atrophy may occur.
Treatment
Wuchereria bancrofti
• Diethylcarbamazine 2 – 6mg/kg daily in divided doses for 2 – 3
weeks. The course is repeated after 6 weeks. Supportive care is
antihistamines or steroids for allergic reactions that can occur. Also
associated bacterial infections should be treated and reconstructive
surgery can be done on unsightly tissue.
Loa loa
• Diethylcarbamazine, 2 - 6mg/kg daily for 2 - 3 weeks
35
Onchocerciasis
• Ivermectin 150mcg/kg orally as a single dose. Annual retreatment
must be given until adult worms die. In endemic areas not all patients
need treatment. Indications for treatment are the threat of eye damage
and severe pruritis.
Prevention
Primary prevention is aimed at vector control and protection of humans from
vectors.
Mass chemotherapy with Diethylcarbamazine is effective in bancroftian
filariasis and loasis.
1.5.1.2. Nematodes - Intestinal
Clinical features
1.5.1.2.1.
Ascaris lumbricoides (Roundworm)
Infection is acquired by ingesting contaminated food. Infection may be
asymptomatic but heavy infections are associated with nausea, vomiting,
abdominal discomfort and anorexia. Worms may obstruct the small intestine.
Heavy infections in malnourished children may worsen the malnutrition.
1.5.1.2.2.
Strongyloides stercoralis
Infection occurs by penetration of the skin by larvae.
After penetration of the skin, a local reaction occurs with itching, erythema,
oedema and urticaria. This subsides within 2 days. A week later migration of
adolescent worms irritates the upper airways, producing cough and
occasionally severe respiratory symptoms. After about 3 weeks, intestinal
colonization occurs leading to abdominal discomfort, intermittent diarrhoea
and constipation.
Heavy infection may lead to persistent diarrhoea, nausea, anorexia and
steatorrhoea.
1.5.1.2.3.
Necator americanus (hookworm)
Local irritation occurs at the site of larval entry in the skin. 2-weeks later mild
and transitory pulmonary symptoms appear. Usually, patients are
36
asymptomatic. Once larvae reach the small intestine with heavy infections
there may be symptoms and signs of anaemia.
1.5.1.2.4.
Trichuris trichiura (whipworm)
Most infections are asymptomatic. Heavy infection is associated with bloody
diarrhoea and mucus, abdominal discomfort, anorexia and weight loss. It may
also cause appendicitis and rectal prolapse in children.
1.5.1.2.5.
Enterobius vermicularis (threadworm)
Intense anal pruritis which is usually nocturnal. Scratching results in
dissemination of eggs.
Diagnosis and Treatment
Ascaris lumbricoides (round worms)
•
Mebendazole 100mg twice daily for 3 days.
Strongyloides stercoralis
•
Thiabendazole 1.5g twice daily for 2 days OR Albendazole. In the
hyper-infected patient with disseminated disease, therapy should be for
5 days or longer. As there may be gram-negative septicaemia in this
group treatment should include intravenous broad-spectrum antibiotics.
Hook worm - Necator americanus
•
Mebendazole 100mg twice daily for 3 days. A repeated course may
be necessary.
Trichuris trichura (whipworm)
•
Mebendazole 100mg twice daily for 3 days.
Enterobius vermicularis
•
A single dose of Mebendazole 100mg followed by a second dose 2
weeks later. Family members should also be treated.
Prevention
Personal hygiene, good sanitation and good living conditions.
1.5.2. Cestodes or Tapeworms
Clinical features
37
Taenia saginata is prevalent in humans in all beef-eating countries. Taenia
solium is found in pork eating areas. Symptoms are mild with vague epigastric
and abdominal pain and occasional diarrhoea and vomiting. Weight loss is
unusual Appendicitis and pancreatitis rarely occur. Proglottids may be found
in the faeces, bed or underclothing.
Diagnosis and Treatment
Praziquantel 10 mg/kg as a single dose.
Prevention
Careful inspection of beef or pork for cysticerci (encysted larval forms)
Refrigeration of beef at -10°C for 5 days or cooking at 57°C for a few minutes.
1.5.3. Trematodes or Flukes
1.5.3.1 Schistosomiasis (Bilharziasis)
This is caused by blood flukes (trematodes). Human infestations occur after
penetration of the skin or mucous membranes by cercaria, the infective form
of the host released by the intermediate snail host into freshwater.
The female fluke produces several hundred eggs a day which penetrate the
venous walls, creating small bleeding into the urine (Schistosoma
haematobium) or stool (Schistosoma mansoni).
Clinical features
The first clinical sign is a local inflammatory response - swimmer's itch.
Within a week or more there is a more generalised allergic reaction with fever,
urticaria and malaise. Nausea, vomiting and profuse diarrhoea as well as
respiratory symptoms namely cough are common.
Complications
Chronic Schistosomiasis with S. mansoni may lead to portal hypertension
with marked hepatosplenomegaly. In S. haematobium infestation there is the
development of dysuria and haematuria. Later there may be the development
of obstructive uropathy, chronic pyelonephritis, renal failure and bladder
carcinoma.
Diagnosis and Treatment
•
Praziquantel tablet
Dose:
38
For Schistosomiasis caused by all species, the usual dosage for adults and
children older than 4 years is 60mg/kg body weight given in three equally
divided doses in intervals of 4 - 6 hours on the same day. Some clinicians
recommend a lower dosage of 40 mg/kg as a single dose or 2 equally divided
doses on the same day, which has been effective in the treatment of
schistosomiasis in some patients.
Prevention:
•
Use of latrines
•
Preventing children from playing in infected water
•
Washing with water from a protected well or boiling for 1 - 2 minutes
or else use water that has been left to stand for more than 48 hours
(this kills the carcaria)
1.6.
GIARDIASIS
Description
An intestinal disease caused by infection with Giardia lamblia. Prevalence is
high in the tropics. Spread is faecal-oral and person to person. The infective
form is the cyst.
Clinical features
Many individuals are asymptomatic and are carriers. Others develop
diarrhoea, nausea, anorexia, abdominal discomfort and distension. Stools may
become pale. If the illness is prolonged, weight loss may develop.
Complication
Growth retardation in children.
Treatment
Adult: Metronidazole 2g as a single dose for 3 successive days. Sometimes
a second or third course may be necessary.
Prevention
•
Personal hygiene
•
Improvement of water quality by boiling water for at least 10 minutes.
The effects of chlorination are variable.
39
2.
CENTRAL NERVOUS SYSTEM CONDITIONS
2.1. MENTAL HEALTH AND PSYCHIATRIC ILLNESSES
Introduction:
The current etiological formulation of mental disorder is based on the
biopsychosocial model meaning symptomatology is as a result of the
interaction of 3 domains: biological, psychological and social. The treatment
approach therefore must consist of the same model.
Psychiatric Disorders
• Anxiety Disorders
• Generalized anxiety disorder
• Obsessive-compulsive disorder
• Social anxiety disorder
• Post-traumatic stress disorder
• Panic attack disorder
Mood Disorders
• Bipolar mood disorder
• Bipolar 1 disorder
• Depressive disorder
• Major depressive disorder
Psychotic Disorders
• Brief psychotic disorder
• Schizophrenia
• Paranoid disorder
• Delusion disorder
Diagnosis for the psychiatric disorders are based on Diagnostic and Statistical
Manual (DSM) IV or International Classification of Diseases (ICD)
2.1.1. Anxiety Disorders
Introduction
The essential feature about these disorders is that a patient has episodic
subjective experiences of false alarm of impending danger when objectively
none exists.
2.1.1.1. Generalised Anxiety Disorder
Description
40
Generalized anxiety disorder is characterized by an excessive level of anxiety
and worry almost all the time and the patient has great difficulties in
controlling the worry. Patients usually present with somatic complaints.
Clinical Features
• Excessive worry about all activities in life
• Anticipation of doom in all undertakings
• Restlessness
• Insomnia
• Tremors
• Muscle tension
• Poor concentration and memory
Differential Diagnosis
The differential diagnosis is extensive because worry and anxiety are seen in
many conditions.
Psychiatric
•
Major depressive disorder
•
Social anxiety disorder
•
Post-traumatic stress disorder
•
Panic attack disorder
•
Anaemia
Medical
• Hyperthyroidism
• Chronic obstructive airways disorders (asthma, emphysema)
• Seizure disorders
• Drug intoxication/withdrawal
• Cardiac arrhythmias
Management
Investigation
• FBC
• TSH (T3, T4)
• Blood glucose
• CXR
41
•
•
EEG
ECG
Treatment
Treatment can either be Psychological (counselling and psychotherapy) or
Psychopharmacological. The two treatment approaches can be used singly or
in combination depending on the etiological factors at play.
Short Term
1. Psychopharmacology
• Alprazolam 0.25mg (250 mcg) given 2 or 3 times daily. If required,
increases may be made in 0.25mg (250mcg) according to the severity
of symptoms and patient response. It is recommended that the evening
dose be increased before the daytime doses. Very severe manifestations
of anxiety may require larger initial daily doses. The optimal dose is
one that permits symptomatic control of excessive anxiety without
impairment of mental and motor function. Exceptionally, it may be
necessary to increase the dosage to a maximum of 3mg daily, given in
divided doses.
Elderly and Debilitated Patients
The initial dosage Alprazolam is 0.125mg (125mcg) 2 or 3 times daily. If
necessary, this dosage may be increased gradually depending on patient
tolerance and response.
Short courses of treatment should be the rule for the symptomatic relief of
excessive anxiety and the initial course of treatment should not last longer
than 1 week without reassessment. If necessary, drug dose can be adjusted
after 1 week. Prescriptions should be limited to short courses of therapy.
• Lorazepam is given as a second-line drug of choice. The initial adult
daily oral dose is 2mg in three divided doses of 0.5mg, 0.5mg and 1mg,
or two divided doses of 1mg and 1mg. The daily dose should be
carefully increased or decreased by 0.5mg depending upon tolerance
and response. The usual daily dose is 2 to 3mg. The optimal dose may
range from 1 to 4mg daily in individual patients. Usually, a daily dose
of 6 mg should not be exceeded.
42
The initial daily dose in elderly and debilitated patients should not
exceed 0.5mg and should be very carefully and gradually adjusted,
depending upon tolerance and response.
• Diazepam 2mg 3 times daily increased if necessary to 10-15mg daily in
divided doses may be used in the absence of the above-mentioned
drugs.
• Sertraline 50mg once per day is recommended as the initial dose. A
gradual increase in dose may be considered if no clinical improvement
is observed. Dose changes, if necessary, should be made at intervals of
at least 1 week. Do not exceed a maximum of 200mg/day. The full
antidepressant effect may be delayed until 4 weeks of treatment or
longer.
Administer with food once daily preferably with the evening meal, or, if
administration in the morning is desired, with breakfast. Used with
caution in patients with renal and/or hepatic impairment.
Maintenance
When a satisfactory clinical response has been obtained, the dose should be
reduced (within the 50mg to 200mg range) to the minimum that will maintain
relief of symptoms.
Psychotherapy – supportive therapy
Long Term
•
Cognitive behaviour therapy
Note
Due to the potential for dependence, Benzodiazepines must be given for 2-6
weeks followed by tapering over a period of 1-2 weeks.
2.1.2. Obsessive-Compulsive Disorder
Description
43
The essential feature is the symptom of recurrent obsessions or compulsions
or both. Obsessions are defined as recurrent, persistent ideas, images or
impulses. Compulsions are behaviours or mental acts that are repetitive,
purposeful, and intentional that are performed in response to the obsession in
a stereotyped fashion.
Clinical Features
Obsessions
Recurrent and persistent ideas, thoughts, impulses, or images that are
experienced as intrusive and senseless and cause marked anxiety or distress.
Thoughts, impulses are not simply excessive worries about problems. The
person attempts to ignore or suppress such thoughts or to neutralize them.
The person recognizes that the obsessions are the product of his or her mind.
Compulsions
Repetitive behaviours or mental acts performed in response to an obsession
or rigidly applied rules. Behaviours are designed to neutralize or prevent
distress or some dreaded event or situation, but are excessive or not
realistically connected with what they are meant to neutralize. The person
recognizes his or her behaviour is excessive or unreasonable (except
children). Obsessions/compulsions cause marked distress, are timeconsuming (more than 1 hr/day), or significantly interfere with the person’s
normal routine. If another axis one disorder is present, the content of the
obsessions or compulsions is not restricted to it. The disturbance is not due
to the direct physiologic effects of a substance or general medical condition.
Differential Diagnosis
1.Obsessive-compulsive personality.
2.Obsessive-compulsive disorder spectrum. Bear similarities with OCD.
3.Trichotillomania
4.Body dysmorphic syndrome
5.Tourette disorder
6. Olfactory reference syndrome
Treatment
Short Term
44
Drugs
• Fluoxetine 20mg/day to 60mg/day is recommended and total dose
should not exceed a maximum of 80mg/day
• Clomipramine
Adults: Initiate with daily doses of 25mg. Dosage may be increased by
25mg, as tolerated, at 3 to 4-day intervals up to a total daily dose of
100mg or 150mg by the end of 2 weeks. Thereafter, the dose may be
gradually increased over several weeks to 200mg. Doses above
200mg/day are not generally recommended for outpatients. However,
in the treatment of severe cases of Obsessive Compulsive Disorder,
daily doses of up to 250mg may be required.
Children and Adolescents: In children aged 10 to 17 years, an initial
dose of 25mg/day is recommended. This may be increased by 25mg, as
tolerated, at 3 to 4-day intervals. By the end of 2 weeks, patients may
be titrated up to 100mg to 150mg/day or 3mg/kg, whichever is lower.
Thereafter, the dose may be gradually increased to 200mg or 3mg/kg
whichever is lower. A total daily dose above 200mg should not be used
in children or adolescents.
Elderly and Debilitated Patients: Initially, 20mg to 30mg daily in
divided doses is suggested, with very gradual increments, depending on
tolerance and response. Blood pressure and cardiac rhythm should be
checked frequently, particularly in patients who have an unstable
cardiovascular function.
Psychological
• Cognitive behaviour therapy
• Exposure and response prevention
Long Term
• Cognitive behaviour therapy (exposure and response prevention).
2.1.3. Social Anxiety Disorder
Description
45
The essential feature of social anxiety disorder is an excessive and persistent
fear of being in a given social situation where the person might be exposed
to the scrutiny of others.
The exposure to or anticipation of the feared situation causes marked anxiety
and the person either avoids the situations or endures it with significant
distress.
Clinical Features
• Tremors
• Palpitation
• Sweating
• Restlessness
These occur in social settings in which patients are preoccupied with feelings
of being negatively evaluated by others.
Differential Diagnosis
1. Shyness
2. Avoidant personality disorder
3. Panic attack
Treatment
Short Term
Drugs
• Alprazolam 250mcg - 500mcg 3 times daily or
• Lorazepam or 1mg - 4mg daily in divided doses as in generalized
anxiety disorders above.
• Fluoxetine 20mg administered once daily in the morning. A gradual
dose increase should be considered only after a trial period of several
weeks if the expected clinical improvement does not occur
Long Term
• Cognitive behaviour therapy.
2.1.4. Post-Traumatic Stress Disorders
Description
46
Post-Traumatic Stress Disorders (PTSD) are caused by severe psychictrauma. A psychic-trauma is defined as an inescapable event that
overwhelms an individual’s existing coping mechanisms.
Clinical Features
The clinical features fall into 3 domains.
1. Re-experiencing
The trauma is re-experienced in the following ways:
a) Frequent intrusive memories of the event
b) Nightmares of the event
c) Flashbacks
d) Low self-esteem
2. Avoidance
All reminders of the events are persistently avoided.
3. Autonomic Hyperactivity
a) Insomnia
b) Irritability
c) Hypervigilance
Diagnosis
Differential Diagnosis
a) Acute stress disorder
b) Adjustment disorder
c) Obsessive-compulsive disorder
d) Schizophrenia
e) Drug/alcohol use disorder (intoxication)
Investigation
None
Treatment
The principal treatment modality for PTSD is psychotherapy, such as
supportive, psychodynamic cognitive-behavioural, and with medication used
to augment the psychotherapy and help reduce the symptoms.
The goals of treatment are:
• To help patients regain self-esteem.
47
• To again feel in control of themselves and their lives (the opposite of
the feelings of helplessness experienced in the trauma).
• To re-work their shattered assumptions.
Phase oriented models are used to conceptualize treatment.
Phase I (Supportive psychotherapy)
Establishing safety, stabilization, symptom reduction and the
therapeutic alliance.
Phase II (Cognitive behavioural therapy)
Dealing with a traumatic event; e.g., through remembering,
desensitization, de-conditioning and mourning.
Phase III (Insight-oriented psychotherapy)
Restructuring personal schema and integrating the trauma into a
meaningful life narrative; i.e., putting the trauma into perspective and
moving forward in developing a positive life.
Drug Therapy
The best approach is to choose a medication based on the more problematic
target symptoms. This may require a combination of medications, e.g., a
Selective Serotonin Reuptake Inhibitor (SSRI) to decrease numbing
(withdrawal from society and becoming emotionally indifferent) and
depression, and a Benzodiazepine (e.g. Lorazepam) and a Beta-blocker (e.g.
Propranolol) (titrate the dose) to decrease autonomic hyperarousal.
2.1.5. Panic Attack Disorder
Description
A panic attack is referred to as a recurrent unexpected discrete episode of
intense discomfort or fear.
Clinical features
Palpitations, pounding heart, or accelerated heart rate, sweating, trembling or
shaking, sensations of shortness of breath or smothering, feeling of choking,
chest pain or discomfort, nausea or abdominal distress, feeling dizzy,
unsteady, lightheaded, or faint, derealisation (feelings of unreality) or
depersonalization (being detached from oneself), fear of losing control or
48
going crazy, fear of dying, paraesthesia (numbness or tingling sensations),
chills or hot flushes.
Diagnosis
It must meet the ICD 10/DSM IV diagnostic criteria.
Differential Diagnosis
 All types of anxiety disorders
 Anaemia
 Angina
 Asthma
 Hyperventilation
 Epilepsy
 Cocaine
 Myocardial infarction
 Migraine
 Transient ischemic attack
 Phaeochromocytoma
 Hallucinogens
Treatment
Short Term
1. Drugs
•
Lorazepam 2mg Initial adult daily oral dosage in three divided
doses of 0.5mg, 0.5mg and 1mg, or two divided doses of 1mg and
1mg. A daily dose of 6mg should not be exceeded. The initial daily
dose in elderly and debilitated patients should not exceed 0.5mg and
should be very carefully and gradually adjusted, depending upon
tolerance and response.
•
Fluoxetine 10mg once initial dose daily for the first week then 20
mg administered once daily in the morning. A gradual dose increase
should be considered only after a trial period of several weeks if the
expected clinical improvement does not occur.
49
Long Term
2. Psychotherapy
a) Behaviour therapy
–Applied relaxation
–Deep breathing exercise
–In-vivo exposure
50
2.2.
MOOD DISORDERS
Introduction
Mood disorders are mental disorders whose primary psychopathology is the
disturbance of mood. The mood disturbances can either be low (depressed)
or high manic/hypomanic.
2.2.1. Bipolar Mood Disorders
This is a spectrum of disorders which is characterized by cyclical disturbance
of mood, cognition and related behaviours. It can either present with
mania/hypomania symptoms or as depression alternating with
mania/hypomania. It consists of:
• Bipolar disorders
• Cyclothymia
• Mood disorder due to general medical condition
• Drug/alcohol-induced mood disorder
2.2.1.1. Bipolar Type I Disorder
Description
It is a subtype of bipolar spectrum of disorders characterized by episodes of
manic presentation or alternating episodes of mania and major depressive
disorder.
Clinical Features
It is subdivided into 3 domains:
1. Biological
• Too busy to eat or sleep (Good appetite and sleep)
• High energy
2. Psychological
• Over familiarity, high self-esteem, grandiose ideas, freely
expressed over-confidence.
3. Social
• Impulsive, disinhibited (unstoppable) and hyperactive.
Diagnosis
A bipolar mood disorder is a spectrum of the disorder. It is critical to make
a definite diagnosis because of treatment implication.
51
Note: Mania is a cluster of signs and symptoms with a variety of underlying
psychopathology. It is not a diagnosis.
Differential Diagnosis
• Major depressive disorder
• Schizoaffective
• HIV
• Syphilitic encephalitic
• Alcohol/drug-induced mood disorder
Investigations
Diagnosis
• Full Blood Count
• Urea & Electrolytes
• Liver function tests (LFT)
• Electroencephalogram (EEG)
• Thyroid-Stimulating Hormone (TSH)
• Vitamin B12
• Pregnancy test
• Pre-treatment Evaluation
A general medical assessment, including history, physical examination, and
laboratory evaluation focusing on organ systems potentially affected by each
agent, is important before starting these medications.
Severity
Treatment
Dosage
Mild†
(Monotherapy)†
Lithium – 300mg 3††
Mood stabilizer†
times a day
Monotherapy†
Carbamazepine – 200 – ††
600mg/day†
Moderate†
Mood stabilizer †
Severe†
Mood stabilizer† and
Antipsychotic†
Sodium valproate ††
250mg†
3 times/day†
††
Severe with†
Mood stabilizer and
psychosis†
Antipsychotic
52
Treatment
Treatment selection depends on illness severity, associated features such as
rapid cycling or psychosis, and, where possible, patient preference.
Short Term
Intermediate
During the intermediate phase, doses will be titrated according to the side
effects, therapeutic effect and drug blood level.
Long Term
Patients will be maintained on the mood stabilizer which results in their
recovery. Antipsychotic must be tapered down slowly over a period of twothree weeks and finally withdrawn.
Note: A blood level of Lithium 0.8-1.2 mEq/L generally is required to treat
the acute onset of episodes of bipolar mood disorders. (A steady-state,
stable blood level the morning before the first dose of the day). Changes
in dosage require monitoring of lithium levels at least every 5-7 days after
the change. Some patients require (and tolerate) levels up to 1.5mEq/L.
although higher levels are not advisable because of the risk of toxicity.
Treatment with lithium alone may have a relatively slow response rate (up
to 2 weeks after a therapeutic blood level) is established.
Lithium should only be used where blood levels of Lithium can be
monitored.
2.2.2. Depressive Disorders
Description
A spectrum of disorders is characterized by a low or depressed mood.
They consist of the following:
• Major depressive disorder single episode
• Major depressive disorder record
• Dysthymia
• Adjustment disorder with depressed mood
• Mood disorder due to general medical condition
53
• Substance-induced mood disorder
It is therefore vital to make a definite diagnosis because of management
implications. They have different treatment, course and prognosis.
2.2.1.1. Major Depressive Disorder
Description
This is one of the depressive spectra of disorders what man
psychopathology is a depressed mood and lack of anhedonia (loss of
interest in all general life activities).
Clinical Features
The clinical presentation falls into 3 domains:
1. Biological:
Insomia/Hyperinsomnia fatigue, weight loss/gain, Agitation/retardation
(psychomotor retardation).
2. Psychological:
Depressed mood, loss of interest in pleasure (anhedonic), sense of
guilt, worthlessness, hopelessness, helplessness and sometimes
suicidal.
3. Cognitive:
Poor attention, concentration and memory.
Diagnosis
Differential Diagnosis
• Bipolar mood disorder with a depressive episode
• Schizoaffective
• Adjustment disorder with depressed mood
• Substance-induced mood disorder
• Mood disorder due to general medical condition
• Sad mood
• Bereavement
Investigations
• FBC, VDRL, TSH, LFT
• Drug Screen.
• Hamilton depressive scale
• Becks depression inventory
54
Treatment
The treatment of major depressive disorder consists of antidepressant,
psychotherapy and electroconvulsive therapy (ECT) or a combination of
these.
Acute Phase
Severity of Major
Depressive Episode
Pharmacotherapy
Mild
Antidepressants if preferred by the patient
Moderate to severe
Antidepressants are the treatment of choice
(unless electroconvulsive therapy (ECT) is
planned)
With psychotic Features Antidepressants plus antipsychotics or ECT
Intermediate Phase
Titrate the medication according to side effect and clinical response.
Long Term Phase
1. Continue with antidepressants
2. Psychotherapy (cognitive behaviour therapy)
3. Taper the antipsychotic and discontinue over the period of three to four
weeks
55
2.3. PSYCHOTIC DISORDERS
Psychosis refers to the loss of contact with reality (impairment in reality
testing). It is not a diagnosis but a symptom of mental disorders with a
variety of underlying etiological factors. It is characterized by delusions,
hallucinations and thought disorders.
2.3.1.
Brief Psychotic Disorder
Description
An acute transient psychotic episode of abrupt onset. Although it can
follow a stressful life event, it may be the first clinical feature of a primary
mental disorder in a predisposed person.
Clinical Features
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g. frequent derailment or incoherence)
4. Grossly disorganized or catatonic behaviour
Investigations
• Full Blood Count
• U&E
• LFT
• TSH
• EEG
• Chest X-ray
• ECG
• Drug Screen.
Differential Diagnosis
1. Schizophreniform
2. Major depressive disorder
3. Bipolar mood disorder
4. Drug/alcohol-induced psychotic disorder
5. Delirium
Treatment
Short Term
1. Hospitalisation:
56
For diagnostic evaluation and monitoring signs and symptoms
2. Psychopharmacotherapy:
• Antipsychotic - See table (flow chart)
• Adjunctive (Benzodiazepine) – Diazepam or Lorazepam
Long Term
The clinical presentation of brief psychotic disorder is polymorphic. A longterm follow-up is advisable to establish the underlying primary mental
disorder.
2.2.3. Schizophrenia
Description
It is a spectrum of disorders which share similar etiological factors but differ
in clinical presentation, course and prognosis.
Clinical Features
• Delusions
• Hallucinations
• Disorganized speech (e.g., frequent derailment or incoherence)
• Grossly disorganized or catatonic behaviour
• Negative symptoms, i.e., affective flattening, alogia or avolition.
Differential Diagnosis
• All psychotic disorders including substance-induced psychotic disorder:
i) Intoxication
ii) Withdrawal states and Psychotic disorder due to general medical
condition
57
Either
Agree on the choice
of antipsychotic with
Patient
Agree on the choice
of antipsychotic with
patient and/or care
Start second-generation
antipsychotic or
Effective
Treatment Algorithm
Or, if not possible:
Or, if not possible:
First-generation
antipsychotic
Titrate, if necessary, to
minimum effective dose Adjust
dose according to response and
tolerability
Assess over 6-8 weeks
Not tolerated or poor
compliance
Not effective
Treatment Algorithm
Either
Continue at
dose
established
as effective
Change drug and
follow
above
process
consider the use
of either an SGA or
an FGA
If poor compliance related
Tolerability,
discuss
with
patient and change drug
Not effective
Repeat above process
Either
investigate
social
or
psychosocial
precipitants
Continue usual drug
treatment
If
poor
compliance
related to other factors,
consider
depot
or
compliance therapy or
compliance aids
Relapse or acute exacerbation
of schizophrenia
(full adherence to medication
confirmed)
Treatment algorithm
Treatment Algorithm
Provide appropriate support and/or
Therapy
Acute drug treatment required
Switch to a different, acceptable
Antipsychotic if appropriate
Assess over at least 6 weeks
If
poor
compliance
related to other factors,
consider
depot
or
compliance therapy or
compliance aids
Treatment ineffective Switch to
clozapine
Relapse or acute exacerbation
of schizophrenia
(adherence doubtful or known
to be poor
Either
Investigate the
reason
for
poor
adherence
Confused
or
disorganized
Lack of insight or
support
Discuss with patient
Consider compliance
therapy or depot
Antipsychotics
Simplify drug regimen
Poorly tolerated treatment
Discuss with the patient
Switch to acceptable drug
58
2.4.
EPILEPSY
Description
This is a recurrent abnormal paroxysmal neuronal discharge. Patients may
present in several forms, i.e. from simple seizures which will only bring
about headache, bad smell or loss of posture and of consciousness to
generalized tonic, clonic seizures (grand mal seizures)
Clinical features
These vary depending on the type of seizure involved.
a)
Generalised tonic to clonic seizures (grand mal)
These may occur with or without the initial warning aura, characterized by
the outcry, loss of consciousness, falling and jerking of the limb s, trunk
and head. Urinary or faecal incontinence may occur. The attack usually lasts
2 to 5 minutes and will be followed by any of the following - deep sleep,
muscle soreness or headache.
b)
Petit mal attacks
Characterized by clouding of consciousness, which could last from 1 - 30
seconds with or without loss of muscle tone. The patient will suddenly stop
all activity and have a blank stare. Activity will only be resumed after the
attack is over. Commonly occurs in children.
c)
Myoclonic seizures
This is characterised by jerking of one or more muscles in any part of the
body with or without consciousness. The jerking may start in one part of
the body and spread.
Diagnosis
Diagnosis is mainly clinical.
Management
The objective is to control the seizures and prevent reoccurrence.
• A detailed history should be taken and should include
• An eyewitness account of the seizure (if possible)
• Prior trauma, infection, alcohol or other drug involvement will call for
a review of the need for continued treatment
• If it is status epilepticus, establish if the patient has been taking the
medication regularly in the last 2 weeks before the seizure (including
dosage and frequency). Record of other medication used recently
History of family seizures or other neurological disorders
59
Treatment
Drugs
Most patients will respond favourably to single-drug treatment on
anticonvulsants (i.e. Phenobarbitone, Carbamazepine or Phenytoin).
Patients who do not respond favourably to maximum doses of these drugs
should be referred for specialist treatment.
Patients who have not had seizures for two or more years, neurological
signs or symptoms, unacceptable behavioural change or adverse reaction to
drugs should all be referred to a specialist for possible discontinuation of
drugs.
Supportive
Counselling is necessary for both the patient and caregivers.
Take blood for:
• Urea and electrolytes,
• Glucose
• Electrolytes: Ca2+, Mg2+
• Full blood count
• Arterial gases, and
• Anticonvulsant concentrations
Investigate and exclude possible underlying causes of seizures, e.g. drugs,
alcohol, meningitis, hypoglycaemia, trauma, etc.
2.5.
FEBRILE CONVULSIONS
Description
These are convulsions occurring mostly among children between six
months and five years. They occur during a bout of fever, which is due to
an underlying infection. In general, the seizures follow the pattern of clonictonic seizures seen in grand mal epilepsy or generalised seizures, but may
be atypical and involve only one side of the body.
Management
Prolonged febrile convulsions of 15 or more minutes or those occurring in
a child of known risk e.g. a child with ventricular peritoneal shunt must be
treated actively.
Drugs
• Diazepam orally or rectally or intravenously 0.6 – 0.5mg/ kg in 24 hours
in divided doses is effective in reducing further febrile seizures in
children.
60
• Paracetamol 10mg/kg 4 times a day as required.
Supportive
• Tepid sponging
• Use of antipyretics
• Caregivers will need counselling about the treatment of recurrences.
61
Commonly Used Anticonvulsants in Adult
SEIZURE TYPE
First-line
Starting
dose
Commonest
Daily Dose
Maintenance
Dose
Dosage Interval
Partial
Seizures Simple
Partial
Complex
partial
Secondary Generalized
Carbamazepine
Lamotrigine
(monotherapy) (Adjunctive VP)
(Adjunctive W/T VP)
Valproate
Phenytoin
100-200mg
25mg
25mg
50mg
50mg
100-200mg
800mg 100mg
25-50mg
300mg 300mg
300mg
400-2000mg
100-200mg
100-200mg
200-400mg
200-400mg
100-700mg
2-4 times a day 12 times a day 1-2
times a day 1-2
times a day 2
times a day
1- 2 times a day
Ethosuximide
Lamotrigine
(monotherapy)
(Adjunctive VP) (Adjunctive W/T
VP) Valproate
500mg
25mg
25mg
50mg
600mg
1000mg 25mg
25mg 300mg
1000mg
1-2 times a day 12 times a day 1-2
times a day 1- 2
times a day 2
times a day
Lamotrigine
(monotherapy)
(Adjunctive VP) (Adjunctive W/T
VP) Valproate Sodium
25mg
25mg
50mg
600mg
100-200mg
25mg
25mg
50mg
50mg
1mg
600mg
25mg 25mg
300mg
1000mg
500-2000mg
100-200mg
100-200mg
200-400mg
10002000mg
100-200mg
100-200mg
200-400mg
10002000mg
400-2000mg
100-200mg
100-200mg
200-400mg
200-400mg
4-8mg
10002000mg
Generalised Seizures
Absences
Atomic/clonic
Tonic-Clonic
Carbamazepine
Lamotrigine
(monotherapy) (Adjunctive VP)
(Adjunctive W/T VP) Valproate
Sodium
Myoclonic
Clonazepam
Sodium
Valproate
62
800mg 100mg
25-50mg
300mg 300mg
6mg 1000mg
1-2 times a day 1-2
times a day 1-2 times
a day 2 times a day
2-4 times a day 1-2
times a day 1-2 times
a day 1-2 times a day
2 times a day
1 at night (3-4 times
a day) 2 times a day
Second-line
Starting Dose
Commonest Daily Dose
Maintenance
Dose
Dosage
Interval
Acetazolamide
250 mg
500-750mg
250-1000mg
3-4 times a
Gabapentin
300mg
600-2400mg
120mg
900 – 1200mg
60-240mg
day 3 times a
Phenobarbitone
30-60mg
Acetazolamide
250 mg
500-750mg
6 mg
250-1000mg
4-8mg
day
1-2 times a
day
Generalized Seizures
Absences
Clonazepam
1mg
Atomic/clonic
Acetazolamide
Carbamazepine
Phenobarbitone Phenytoin
250mg
100-200mg
30-60mg
100-200mg
500-750mg
800mg
120mg
300mg
250-1000mg
400-2000mg
60—240mg
100-700mg
3-4 times a
day 3 times a
day
1-2 times a
day
1-2
times a day
Tonic-Clonic
Acetazolamide
Gabapentin
Phenobarbitone
250mg
300mg
3060mg
500-750mg
600-2400mg
120mg
250-1000mg
600-2400mg
60-240mg
250-1000mg
600-2400mg
1-2 times a
day
Myoclonic
Acetazolamide
120mg
500-750mg
250-1000mg
3-4 times a
day
SEIZURE TYPE
Partial
Seizures
Simple
Partial
Complex
partial
Secondary
Generalized
3-4 times a
day
1 at night (or
3-4 times a
day)
Commonly Used Anticonvulsants in Children
63
Condition
Partial Seizures
Simple Partial
Complex partial
Secondary Generalized
First-line
Starting
dose
(mg/kg per
24 hours)
Target dose
for initial
assessment
of
effect (mg/kg
per 24 hours)
Incremental
Size (mg/kg
per 24 hours)
Dose Interval
(days)
Usual
Effective
dose (mg/kg
per
24
hours)
Frequenc
y
of
dosing
(times per
24 hours)
Carbamazepine
Lamotrigine
(monotherapy)
(Adjunctive
VP)
(Adjunctive W/T VP)
Valproate
5
150microgra
m
300microgra
m
5-7.5
1.5-2.5
12.5
-
2.5
300microgra
m
300microgra
m
10
2.5-5
3-7
-
12-25
1-5
1-5
12.5-15
2-3
1-2
1-2
2
5-9
1-2
5
150microgra
m
300microgra
m
5-7.5
15
150microgram
10
150microgra
m
300microgra
m
5-7.5
15
150microgra
m
300microgra
m
5-7.5
10-20
1-5
2
1-2
1-5
1-2
12.5-15
2
150microgra
m
300microgra
m
5-7.5
150microgram
150microgra
m
300microgra
m
5-7.5
150microgra
m
300microgra
m
5-7.5
150microgra
m
300microgra
m
5-7.5
5
150microgra
m
300microgra
m
5-7.5
12.5
150microgram
5-7.5
2.5
150microgra
m
300microgra
m
5-7.5
3-7
150microgra
m
300microgra
m
5-7.5
12-25
150microgra
m
300microgra
m
5-7.5
50microgram
1
1
50microgram
1
5-7.5
5-7.5
5-7.5
5-7.5
12.5-15
Phenytoin
Generalized Seizures
Absences
Ethosuximide
Lamotrigine (monotherapy)
(Adjunctive VP)
(Adjunctive W/T VP)
Valproate
Atomic/Clonic
Lamotrigine (monotherapy)
(Adjunctive VP)
(Adjunctive W/T VP)
Valproate Sodium
Tonic – Clonic
Myoclonic
Carbamazepine
Lamotrigine
(monotherapy)
(Adjunctive VP)
(Adjunctive W/T VP)
Valproate Sodium
Clonazepam
Valproate Sodium
30
7
300microgram
5-7.5
300microgram
5-7.5
300microgram
64
1
4
14
10
10
1-2
1-2
2
2-3
150microg
ram
300microg
ram 5-7.5
1-2
SEIZURE TYPE
Partial
Seizures
Simple
Partial
Complex
partial
Secondary Generalized
Generalized Seizures
Absences
Atomic/clonic
Tonic-Clonic
Myoclonic
Second-line
Starting
dose
(mg/kg per
24 hours)
Target dose for initial
assessment of effect (mg/
kg per 24 hours)
Incremental
Size
(mg/kg
per 24 hours)
Dose
Interval
(days)
Usual
Effective
dose
(mg/kg per
24 hours)
Frequency
of dosing
(times per
24 hours)
Acetazolamide
2.5
7.5
5-7
1
5-7
2-3
Gabapentin
Phenobarbiton
e
10
1-1.5
10
1-1.5
0
2
1,2,3
1
10-20
2.5-5
11-2
Acetizolamide
Clonazepam
2.5
50microgram
7.5
1
5-7
1
1
50microgra
m
5-7
12.5-15
2-3
1
Acetazolamide
Carbamazepin
Phenobarbiton
e Phenytoin
2.5
5
1-1.5
1.5-2.5
5-7.5
10
1-1.5
7.5
5-7
2.5
2
2.5-5
5-7
2.5-5
2.5-4
2.5-5
2-3
2-3
1-2
2
2.5
10
1-1.5
5-7.5
10
1-1.5
5-7
0
2
5-7
10-20
2.5-4
2-3
1
2-3
2.5
5-7.5
5-7
5-7
2-3
Acetazolamide
Gabapentin
Phenobarbiton
e
Acetazolamide
1
3-7
1
1
1
1,2,3
1
1
65
2.6.
RABIES
Description
This is a disease caused by a virus that affects brain cells. This virus is
usually found in animal vectors and is transmitted to man.
Vectors which may carry the rabies virus, include:
Domestic
Wild animals:
animals:
•
Hyenas
•
Dogs
•
Foxes
•
Cats
•
Wild
dogs
•
Bats
Clinical features
Fulminant encephalitis with convulsions, circulatory and respiratory
failure. Hydrophobia (fear of water) occurs in advanced stages of the
disease.
Diagnosis
Investigation
• Taking a good history
• Laboratory investigation using immunofluorescent microscopy of
smear from the cornea or of a skin biopsy
• Brain examination of dead animals or sacrificed animals
Treatment
Standardised treatment of all animal bites and scratches; these should be
thoroughly cleaned and flushed with soap and water.
Antibiotics and Tetanus toxoid should also be administered.
Administration of anti-rabies vaccine as soon as possible after exposure.
The human diploid vaccine may be used as follows:
66
Condition of animal
Treatment in case of Bite
Lick
Healthy, vaccinated with a
valid certificate
Healthy, not vaccinated
None
None
None
Unknown or escaped
Vaccine
Vaccine
+
Rabid or suspected
Vaccine + serum
serum
Recommended regimen:
1 dose to be given on Day 0; Day 3; Day 7; Day 14 and Day 28.
If the animal is proved to be healthy after the tenth day, no more vaccine is
necessary.
All bites by rabid dogs should be reported to the nearest Veterinary Office.
Prevention
Veterinary precautions, which include vaccination of domestic animals,
eradication of stray dogs and surveillance control of the epidemiological
situation in the wildlife population.
Pre-exposure vaccination:
This is administered to high-risk population groups, e.g. veterinary staff and
wildlife department personnel. Two doses of human diploid vaccine with
one month’s interval, followed by a booster after one year. Repeat booster
after every three years.
67
3.
INFECTIONS
3.1. MALARIA
Description
Malaria is a protozoal infection by the genus Plasmodium. It is transmitted
through the bite of an infected female mosquito belonging to the genus
Anopheles. It is characterised by paroxysms of chills, fever and sweating, and may
lead to anaemia and splenomegaly.
Malaria parasites comprising 4 species, each one with a different biological
pattern may affect man. Plasmodium vivax, Plasmodium falciparum, Plasmodium
malariae and Plasmodium ovale. In Zambia, Plasmodium falciparum is the most
prevalent.
Clinical features
Diagnosis
• Take a good history and include all the physical examination and make a
differential diagnosis.
• Confirm m the presence of parasites and complications by laboratory methods
3.1.1.
Uncomplicated Malaria
Prodromal symptoms are usually non-specific and are often characterise d by
intermittent febrile illness. Fever is the most common symptom. Headache, aching
joints, back pain, nausea and vomiting and general discomfort usually
accompany the fever.
The patient may not present with fever but may have had a recent history of fever.
This is due to the natural malaria cycle. A history of fever during the previous
two days along with other symptoms of malaria is a critical basis for suspected
malaria.
It is equally important to note that fever is a common symptom for other
infections besides malaria, such as ear infections, measles and pneumonia.
Malaria has been nicknamed "the Great Imitator" because of this. The
possibility of other infections, either co-existing with malaria or as the sole cause
of fever, should always be borne in mind in arriving at the diagnosis. It is
therefore important to carry out a differential diagnosis.
In children, the onset of malaria may be characterized, in the early stages, only
by symptoms like poor appetite, fever, restlessness, cough, diarrhoea, malaise and
loss of interest in the surroundings.
68
3.1.2.
Severe Malaria
P. falciparum infection in the presence of any life- threatening condition is
considered as severe malaria. All life-threatening conditions and the presence of
any danger signs in the presence of an acute febrile illness should be considered as
possible severe malaria. Some of the danger signs include:
• Excessive vomiting
• Inability to drink or breastfeed
• Extreme weakness
• Convulsions
• Drowsiness
• Loss of consciousness
• Abnormal breathing
Severe headache, sleepiness and loss of consciousness are some of the
commonest indications of severe malaria. Jaundice is another early sign.
A patient in whom malaria is suspected and is severely ill requires urgent
attention and should be referred to an appropriate health facility, where
applicable. Severe malaria particularly in pregnant women and children
under five should be managed as an emergency.
Other symptoms and signs of severe malaria include:
• Convuls ions (> 2 episodes within 24 hours)
• Coma or altered level of consciousness
• Drowsiness/lethargy
• Prostration (inability to sit or stand without support)
• Respiratory distress
• Pulmonary oedema
• Shock (cold moist skin, low blood pressure, collapse)
• Severe vomiting
• Severe anaemia (Hb <5g/dl or HCT <15%)
• Haemoglobinuria
• Hypoglycaemia (blood glucose <2.2mmol/L or<40mg/%)
• Splenomegaly
• Hepatomegaly
• Abnormal bleeding (spontaneous prolonged bleeding from puncture
sites).
Initial Management of Severe Malaria
Antimalarial Treatment
69
For severe (complicated) malaria, Quinine is recommended, however,
intravenous Artesunate could be used as an option to Quinine in treatment
of severe malaria where available.
Give Artesunate intravenously. If intravenous administration is not
possible, Artesunate may be given intramuscularly into the anterior thigh.
Children: Artesunate 2.4 mg/kg BW IV or IM given on admission (time =
0) then at 12 hr and 24 hr, then once a day is the recommended treatment.
Adults: Artesunate 2.4 mg/kg BW IV or IM given on admission (time = 0)
then at 12 hr and 24 hr, then once a day is the recommended treatment.
Give 2.4 mg/kg body weight IV or IM stat, repeat after 12 hours and 24
hours, then once daily afterwards. However once patient regains
consciousness and can take orally, discontinue parenteral therapy and
commence the full course of recommended ACT, such as Artemether +
Lumefantrine fixed-dose combination.
Signs and symptoms of uncomplicated malaria
Uncomplicated Malaria
M Severe
o malaria
d
e
r
a
t
e
l
y
and
complicated
s
e
v
e
r
e
M
a
l
a
r
i
a
Fever (<_37.5 0C)
N Severe anaemia (Hb<5g/
a dl)
u
s
70
e
a
Headache
V Jaundice
o
m
i
t
i
n
g
Sweats and chills
D Drowsiness
e
h
y
d
r
a
t
i
o
n
Body pains
D Shock
i
a
r
r
h
o
e
a
Acute gastroenteritis
E Convulsions
x
t
r
e
m
e
w
e
a
k
n
e
s
s
Respiratory distress
Unconsciousness/coma
71
Change in behaviour
Hyperparasitaemia
Prostration, i.e., generalized
weakness, inability to stand
or walk)
Abnormal bleeding
Treatment
Uncomplicated Malaria
1.
The first line of treatment for malaria is Artemisinin-based combination
therapy. For instance:
Artemether 20mg + Lumefantrine 120mg tablets
Artemether + Lumefantrine recommended dosing:
Age (years)
Weight
(kg)
Number of tablets Artemether (A)
+ per dose 0h, 8h, Lumefantrine (L)
24h, 36h, 48h, 60h per dose
<1
<5
Not recommended
1 -5
5-14
1
20m
g A +
120mg L
6 -8
15-24
2
40
mg A +
240mg L
9 -12
25-34
3
60m
g A +
360mg L
Over 12
>35
4
80m
g A +
480mg L
Artemether 20mg + Lumefantrine 120mg is not recommended in pregnancy
and lactating mothers. Where there is no suitable alternative drug, it should
be used.
72
For those weighing 5kg body weight and below, the drug of choice is
Sulphadoxine 500mg + Pyrimethamine 25mg for uncomplicated malaria.
The dosage for Sulphadoxine 500mg + Pyrimethamine 25mg is a single
treatment of half a tablet.
Sulphadoxine + Pyrimethamine recommended dosing:
Wt (kg)
5-10
10.1-14
14.1-20
20.1-30
30.1-40
40.1-50
>50
Age (years)
2-11months
1-2
3-5
6-8
9-11
12-13
14+
Number of Tablets
0.5
0.75
1
1.5
2
2.5
3
For unconscious, persistently vomiting, convulsing or severely ill patients,
treat as complicate maa, resuscitate refer.
Severe Malaria
Children:
By intramuscular injection; Quinine 10mg/kg body weight diluted in saline
or water for injection (to a concentration of 60 – 100mg salt/ml), repeated
after 4hrs and then 12 hourly. A loading dose is not recommended by this
route. By intravenous injection; Quinine loading dose of 20mg/kg body
weight diluted in 10ml of 5% or 10% dextrose (or isotonic fluid if
hypoglycaemia is excluded) per kg body weight by intravenous infusion
over 4 hours. After 12hours maintenance dose of 10mg/kg body weight
given over 2 hours, repeated 12 hourly until the patient can swallow, then
oral Quinine 10mg/kg body weight 8 hourly to complete a 7-day course of
treatment.
Adults:
By intramuscular injection, Quinine 10mg/kg body weight diluted in saline
or water for injection (to a concentration of 60 – 100mg salt/ml), repeated
after 4hrs and then 12 hourly. A loading dose is not recommended by this
route. By intravenous injection; Quinine loading dose of 20mg/kg body
weight diluted in 10ml of 5% or 10% dextrose (or isotonic fluid if
hypoglycaemia is excluded) per kg body weight by intravenous infusion
over 4 hours. After 8 hours maintenance dose of 10mg/kg body weight
given over 4 hours, repeated 8 hourly until the patient can swallow or after
coma resolution, then oral Quinine 10mg/kg body weight 8 hourly to
complete a 7-day course of treatment.
73
Oral Quinine 300mg tablet dosage schedule
Age Years
Number of tablets per dose
<1
0.25
1-3
0.5
4-6
0.75
7-11
1
12-15
1.5
15+
2
Quinine is sometimes used in combination with Tetracycline or
Clindamycin, Doxycycline in places where there is reduced sensitivity to
Quinine. In Zambia, Quinine sensitivity Is still very high and there is no
justification for using the combination.
3.1.3.
Malaria in Pregnancy
Intermittent presumptive treatent (IPT) – Sulphadoxine + Pyrimethamine is
the drug of choice for prevention of malaria in pregnancy. Sulphadoxine +
Pyrimethamine is given after 16 weeks following the last menstrual period
(LMP). Two consecutive doses are given at least 4 weeks apart during the
second and third trimester. A total of 3 doses should be given during the
entire duration of pregnancy.
Individuals who are intolerant to SP should be counselled about personal
preventive measures to reduce contact with mosquitoes.
Summary of management of Malaria



Take and record a confirmatory history
Do a confirmatory cli nica l assessment including body temperature.
Make a differential diagnosis on clinical basis.
74

Do a lumbar puncture if there is need to exclude meningitis
Prepare a thick and thin blood smear
 Do a full blood count
 Decide on treatment and method of administration.
 Keep treatment, follow-up and referral records. Record treatment failures and
adverse events.
 Give oral, subcutaneous or intramuscular medications
 Decide on the need for referral
Supportive therapy


Monitoring of fluid and electrolyte balance
Correction of fluid and electrolyte imbalance

Correct management of anaemia

Management of hypoglycemia

Management of any other complications
Referred Patients

Patients referred from the community need to have a thorough cl inica l
examination to exclude other causes of fever.
Criteria for Referral from theHealth Centre to Hospital
The following are criteria for a referral from the Health Centre to Hospital:
• Neurological manifestation e.g. convulsions and altered/disturbed
consciousness.
Persistent vomiting
Hyperpyrexia (>39 0C).
Hypothermia (< 35.7 0C).
Severe Anaemia.
Jaundice.
Pregnancy with fever
Failure to respond to treatment after 2 days.
Reaction to drugs interfering with normal daily activity e.g. severe
rash, severe itch, sulphonamide sensitivity.
• Conditions that cannot be managed locally
• Rapidly deteriorating condition of the patient.
• Conditions that cannot be managed locally
•
•
•
•
•
•
•
•
75
Prevention
• Get rid of mosquito breeding sites near residential areas
• Use impregnated mosquito nets, repellents and sprays
• Give public health education on the dangers of malaria and how to
prevent it.
Counselling Points:
• Provide health education information on malaria i.e. personal
protection measures e.g. bed nets, repellents, general sanitation around
the house and in the community, such as reducing breeding sites and
clearing of vegetation.
• In Children; advise caregiver on the need for growth monitoring,
feeding, Vitamin A supplementation and immunisation in children.
• Prophylaxis in sickle cell anaemia and post-splenectomy use
Pyrimethamine 25mg once weekly.
Zambia has no prophylaxis policy for visitors. Recommendations are
provided from their country of origin. Some countries e.g. the United Kingdom are
using Mefloquine. Sulphadoxine + Pyrimethamine is not recommended for this
purpose.
The use of other drugs like Amodiaquine, Dapsone-Pyramethamine,
(maloprim) and Mefloquine for prophylaxis needs further evaluation and is
not therefore recommended.
76
3.2.
TUBERCULOSIS
Description
Tuberculosis is an infectious disease that is caused by the tubercle bacillus,
Mycobacterium tuberculosis. The principal route of infection is the respiratory
tract through the inhalation of infected air droplet nuclei.
Infection may rarely occur through the gastrointestinal tract from the ingestion of
infected unpasteurised milk. Exposure to infection may lead to infection which
may be latent.
Subsequent progression to active disease occurs in approximately 100/o during
the lifetime in people with a latent infection and an intact immune system.
Progression of a latent infection occurs at a higher rate in individuals infected
with the Human lmmunodefi ciency Virus.
In HIV-infected patients, pulmonary tuberculosis is the commonest form of
tuberculosis.
3.2.1.
Pulmonary Tuberculosis
Pulmonary tuberculosis classically presents with symptoms of prolonged cough
(>2 weeks duration), which is usually productive; and with or without a history
of haemoptysis, fever, night sweats and loss of weight. Radiological changes
that occur include cavitation, parenchymal infiltrates and lymphadenopathy.
Sometimes Chest X-rays may not show any abnormality. Radiological findings
in HIV-infected individuals depend on the degree of immunosuppression.
Atypical findings are more common in these patients.
Clinical features
Pulmonary Tuberculosis accounts for approximately 800/o of the cases of
tuberculosis, with smear-positive tuberculosis being the major source of infection.
Extra- pulmonary tuberculosis may involve many sites of the body such as the
pleura, pericardium, lymph nodes, meninges, bones, gastrointestinal tract, genitourinary system, epididymis, eyes and skin.
3.2.2.
Pleural tuberculosis
Pleural tuberculosis may present with a cough which may be non-productive,
pleuritic chest indent pain, systemic symptoms of fever and night sweats.
77
3.2.3.
Pericardial tuberculosis
Pericardial tuberculosis may present with chest pain or with features of tamponade
suc has dyspnoea, tachycardia, hypotension, pulsus paradoxus and sudden collapse
of the patient.
3.2.4.
Lymph node tuberculosis
Lymph node tuberculosis may affect any site though it is more common in the
cervical region. Lymph nodes are usually painless. Where caseation with
liquefaction and sinus formation occurs, they may be painful.
3.2.5.
Meningeal tuberculosis
Meningeal tuberculosis is usually of insidious onset with symptoms of headache,
neck stiffness, indent vomiting and disordered consciousness.
3.2.6.
Bone tuberculosis
Bone tuberculosis may affect any bone though it is more common in the
thoracolumbar spine leading to gibbus formation due to vertebral collapse and
may result in paraplegias. Osteomyelitis and cold abscess formation may also
occur.
3.2.7.
Gastrointestinal tuberculosis
Gastrointestinal tuberculosis may affect any part of the gastrointestinal tract,
though intestinal involvement presenting as diarrhoea, malabsorption,
intestinal obstruction and ascites are common.
3.2.8.
Genito-urinary tuberculosis
Genito-urinary tuberculosis involving the kidneys may be asymptomatic, causing
symptoms such as haematuria and sterile pyuria with extensive renal involvement.
Infertility, salpingitis and tubal abscess are presentations of infection of the
fallopian tubes while epididymal tuberculosis may present as painless swellings.
Phylectenular conjunctivitis, iritis and choroiditis are manifestations of eye
infection.
3.2.9.
Dermal tuberculosis
Dermal tuberculosis may include lupus vulgaris and erythema nodusum.
3.2.10. Adrenal tuberculosis
Adrenal tuberculosis may cause Addison's disease.
78
Complications
Complications of pulmonary tuberculosis include pneumothorax, empyema
or pyopneumothorax and laryngitis with advanced disease. Respiratory failure
and right ventricular failure may develop as a late complication due to extensive
pulmonary destruction and fibrosis.
Colonization of cavities with Aspergillus fumigatus may occur resulting in
haemoptysis.
Constrictive pericarditis is a complication of TB. Meningeal tuberculosis as a result
of TB of the spine may result in permanent neurological deficits.
Gastrointestinal tuberculosis may lead to the development of ascites and
malabsorption.
Diagnosis
Take good history, chest x-ray, sputum smear, ESR and Hb. Tuberculin test
to make an informed decision.
Treatment
Treatment of tuberculosis should be based on the demonstration of the
mycobacteria by both sputum smear histology and culture. Clinical and
radiological findings of dual HIV/TB infection have changed. Identification
of smear-positive cases should form the basis for treatment as these are
cases responsible for continued transmission of infection. In the presence
of a clinical picture, treatment may be started using standard treatment
Directly Observed Therapy (DOTs). The basic principle underlying the
treatment of tuberculosis is the use of multi-drug treatment regimen for a
prescribed period to avoid the development of drug resistance. There is no
place for the use of monotherapy in the treatment of tuberculosis nor for a
trial of treatment.
Drugs
Treatment for tuberculosis is provided free of charge in all public health
institutions. The basis of treatment for tuberculosis is the use of multi-drug
treatment for 8 months. Directly Observed Treatment (DOTs) is the
mechanism by which the supervision of each dose of the drug occurs,
ideally by a member of the health care staff or by family, friends or
community health workers.
Treatment is divided into an Intensive phase in which the patient should
visit the clinic daily for review and medication for the first two months,
followed by a continuation phase of 6 months whereby the patient visits the
clinic once every 4 weeks to collect drugs.
79
Pyridoxine supplement of 50mg daily should be given throughout treatment
and especially so in lactating and pregnant women.
Corticosteroids are indicated in meningeal and pericardial tuberculosis and
should be started at the same time as antituberculosis therapy. There may
be a need for pericardiocentesis in TB pericarditis.
For adults and children, treatment of tuberculosis has been classified into
two categories as follows:
Adults
Paediatrics
Category I
Category II
Category I
Category II
New
smear
positives (+) Smear
negative (-) and
extrapulmonary
Smear +
New
uncomplicated
cases of TB
Retreatment
cases
and
severe,
complicated
TB. i.e., TB
meningitis,
miliary TB,
spinal TB
re-treatment
cases
including
treatment
failure,
treatment
after default,
and relapses
for
smearpositive cases
a) Recommended Adult Treatment Dosage
Category I: New smear-positive patients
Weight in kg
Intensive
months
phase
2
Continuation Phase 6 months
RHZE
EH
30-37
2
1
38-54
3
2
55-70
4
3
>70
5
3
R – Rifampicin, H – Isoniazid, Z – Pyrazinamide, E – Ethambutol, S –
Streptomycin.
80
Category II: Smear positive re-treatment patients
Weight
Intensive Phase 3 months
Continuation Phase
5 months
2 months
1 month
RHZE + S
RHZE
30-37
2
0.5g
2
2
38-54
3
0.75g
3
3
55-70
4
1.0g
4
4
>70
5
1.0g
5
RHE
5
Recommended Paediatric Treatment Dosage for Newly diagnosed,
Uncomplicated Tuberculosis
Weight in Kg
Intensive phase 2months
RH + Z
Continuation phase 4
months
RH
6 –11
1/2
1/2
1/2
12 – 18
1
1
1
19 – 26
1 1/2
1
1 1/2
27 – 37
2
1 1/2
2
> 38
3
2
3
Pregnancy and Breastfeeding:
The standard regimen (above) may be used during pregnancy and
breastfeeding; Pyridoxine supplements are advisable. Streptomycin should
not be given in pregnancy.
In exceptional circumstances, Ethambutol can be used in young children (e.g.
drug resistance ). However, care is needed in young children receiving this drug
81
because of the difficulty involved in obtaining reports of visual symptoms and
in testing eyesight.
3.2.11. Multidrug-resistant Tuberculosis (MDR-TB)
Multidrug-resistant tuberculosis (MDR-TB) is a form of tuberculosis that is
resistant to two or more of the primary drugs isoniazid and Rifampicin used for
the treatment of tuberculosis. In Zambia, the Chest Diseases Labora tory reported
Multi-drug resistant (MDR) that is resistance was 1.8% for new cases and 2.3%
for previously treated cases 2003.
All suspected MDR-TB specimen should be referred to the national TB reference
laboratory. MDR-TB patients should be referred for specialist treatment and where
appropriate facilities for infection control exist.
Use at least four drugs with either certain or almost certain, effectiveness.
Drug Susceptibility Testing (DST) should generally be used to guide therapy.
Ciprofloxacin must not be used as an antituberculosis agent because of its weak
efficacy compared with other fluoroquinolones. Patients should be treated for
18 months of past culture conversion. There is a role for adjunctive measures
such as surgery and nutritional and social support which should be used
appropriately.
Treatment involves the use of drugs from group 1 to group 4. Group 1 drugs are
first-line drugs to which resistance has not been documented. Efficacy for a firstline drug should be questioned if it was used in a previously failed regimen
despite a DST report to the contrary.
Group 2 drugs are the injectables either Amikacin or Kanamycin. Capreomycin
may be used when there is resistance to Amikacin or Kanamycin.
Group 3 drugs include fluoroquinolones such as moxifloxacin, gatifloxacin,
levofloxacin and ofloxacin.
Group 4 drugs are added based on estimated susceptibility, drug history,
efficacy, side-effect profile and cost.
Ethionamide or Prothionamide is often added because of low cost; however, these
drugs do have some cross-resistance with Isoniazid. Cycloserine is used often in
conjunction with either Ethionamide or Prothionamide when group 4 drugs are
required.
Group 5 drugs are not recommended by WHO for routine use in MDR-TB treatment
because their unclear efficacy regimens are unclear in humans.
82
Most of these drugs are expensive, and in some cases require intravenous
administration. However, they can be used in cases where adequate regimens are
impossible to design with the drugs from group 1-4.
Group 5 include Clofazimine, Linezolid, Amoxicillin/clavulanate,
Thioacetazone, Imipenem/cilastatin, high-dose Isoniazid, Clarithromycin.
3.2.12. Extensively Drug-Resistant Tuberculosis (XDR-TB)
Recognized earlier in 2006 in South Africa, extensively drug-resistant TB (XDR-TB)
is MDR-TB that is also resistant to three or more of the six classes of second-line
drugs. Currently, there is no documented evidence of XDR -TB in Zambia.
3.2.13. Tuberculosis and Immunocompromised Patients
All TB diagnosed patients should be counselled and tested for HIV.
Immunocompromised patients may develop tuberculosis owing to reactivation of
previously latent disease or due to new infection. Multi-resistant Mycobacterium
tuberculosis may be present or the infection may be ca use d by other
mycobacteria e.g. M. avium complex in which case specialist advice is needed.
Culture should always be carried out and the type of organism and its
sensitivity confirmed. Minimum duration of treatment of 9 months is
currently recommended for M. tuberculosis infection as re-infection is a
common feature in these patients.
In TB/HIV co-infection, treat all patients for TB regardless of CD4 count.
Start ART as soon as TB medications are tolerated (usually within 2 – 3
weeks). AR is not required for all patients with CD4 count >350 and no
other Stage III or IV illness. Use an Efavirenz-based ART regimen. If
patient has renal insufficiency ABC + 3TC + EFV is an alternative option.
In patients already on ART. Start TB treatment immediately. If on LPV/rcontaining ART regimen, start Rifabutin in place of Rifampicin or add
Ritonavir 300mg BD or double the dose of LPV/r. Evaluate for clinical
failure and consider for second-line ART in consultation with HIV
specialist.
If pregnant woman on ART, refer to the section of this guideline on
HIV/AIDS Treatment or refer to HIV specialist. If on anti-TB treatment and
tests positive for HIV, start ART as soon as baseline laboratories and
treatment preparation completed.
Monitoring
83
Since Isoniazid and Rifampicin are associated with liver toxicity, the
hepatic function should be checked before and during treatment with these
drugs. Patients on dual treatment of HIV and TB are likely to have
liver/renal toxicity and should therefore be monitored closely.
Supportive
Non-adherence is the major reason for the failure of otherwise effective
drug regimens to achieve high cure rates in the management of tuberculosis.
Both patient-related and service-related factors contribute to poor patient
compliance. Hence, the education of both healthcare staff and patients is an
important part of the management package. An adequate system of
defaulter-tracing would also contribute to higher cure rates. In areas with
high rates of dual HIV/TB co-infection, nutritional support and integration
of Home-Based Care units and the treatment of tuberculosis is important to
ensure that supervision of treatment occurs. Hospitalisation during the first
two months of treatment is not routinely done and is reserved for those who
are severely ill or who have complications of the disease.
Prevention
The most effective method of preventing the spread of tuberculosis is the
detection and effective treatment of the infectious cases, i.e. the smearpositive cases. The effectiveness of vaccination using BCG is controversial
with results of efficacy studies varying from 0% to 80%. The current WHO
recommendation is that BCG should be given at birth to infants in high
prevalence areas but avoided where the HIV disease is symptomatic.
Poor hygiene, malnutrition and overcrowding in places such as prisons,
orphanages, boarding schools and others facilitate the spread of
tuberculosis. Hence the fight against should involve the improvement of
socio-economic factors. In the case of childhood TB, contact tracing of an
adult should be made, as well a drug treatment.
Prophylaxis
If a child is exposed to positive pulmonary TB, particularly under 5 years
of age, provide prophylactic treatment with Isoniazid 5mg/kg orally once
daily for 6 months.
3.3.
MENINGITIS
Description
84
This is inflammation of the meningeal covering of the brain or spinal cord.
Both brain and meninges can be involved. This inflammation could be caused by
bacteria, viral or fungal infections, malignancies, chemical reaction, intrathecal
infections and also due to injury or trauma.
Clinical Features
Cli nical presentation is the same despite different causative agents; but the
commonest causative agent is bacteria and these include, Gram-negative organisms
i.e. E. coli in children, H. influenzae type b, group B Streptococcus,
Streptococcus pneumoniae, Neisseria meningitidis and Cryptococcus in immunecompromised patients. Factors such as age, head trauma, and compromised
immunity may help predict causative agents.
The relative incidence of meningitis for children remains high in the first 2 years
of life. The incidence of meningitis is high during the 1st month of life with most
infections being due to gram-negative organisms i.e. E-Coli in children and
group B Streptococcus.
Presentation of patients with meningitis varies according to age group.
Adults and older children
• Headache
• Neck stiffness/ ache
Common presentations
• Fever
• Vomiting
• Seizures
• Confusion
• Drowsiness
• Loss of consciousness
• Vascular collapse (Waterhouse - Friderichsen syndrome)
In infants
• Fever
• Vomiting
• Irritability
• Convulsions
• High-pitched cry and
• Bulging of the anterior fontanel is commonly present
• Stiffness of the neck may be absent
• There may be enlarging of head size
Signs of Meningitis
85
Other signs elicited during a physical examination that suggest meningitis
include:
•
•
•
•
Neck stiffness
Positive kernig's sign
Brudzinski' s sign
Cranial nerves abnormality may occur (facial nerve palsy, oculomotor
nerve palsy and occasional deafness).
Complications
These include:• seizures
• loss of consciousness
• hydrocephalus, thrombophlebitis
• cranial palsies
• hemiplegia and
• death.
Long term complications include mental retardation, hearing loss, sometimes
blindness, epilepsy.
Diagnosis
This is confirmed by laboratory investigations. Perform a lumbar puncture for
gram-stain culture and sensitivity for glucose and protein.
Cerebral spinal fluid may be cloudy, indicating bacterial meningitis.
3.3.1.
Bacterial Meningitis
Initial therapy should be guided by the patient's age, the clinical circumstances,
and suspected pathogen and later by the CSF results. Antibiotics are the mainstay
of therapy and should be instituted parenterally at the initial stage.
Benzylpenicillin or Ampicillin is given I.V.
Adults:
Benzylpenicillin 4 mega units I.M or Ampicillin 100mg - 200mg/kg I.V. 6
hourly.
The Penicillin is usually given with Chloramphenicol injection at a dosage of
50 - 100mg/kg every 6 hours.
Intrave nous antibiotic injection should be put in place for the first 72 hours or for
as long as the patient is unconscious and then changed to the oral form.
86
Treatment should generally be continued for at least 1 week after the fever
subsides and the CSF returns towards normal.
The various antibiotics and combinations used in bacterial meningitis include:
In infants:
Ampicillin 100 -150mg/kg I.V (0 - 7 days old) 8- 12 hourly or 150 - 200mg/kg
I.V (> 7 days old) 6 - 8 hourly plus Cefotaxime 200mg/kg I.V. every 6 hours.
Ampicillin, as above plus Gentamycin, 7.5mg/ kg I.V (0 - 7 days old) 8 hourly or
5mg/kg I.V. (> 7 days old) 12 hourly.
In children >1 month-old, Cefotaxime, as above or Ceftriaxone 20 -50mg/kg
daily as a single dose can be increased up to 80mg/kg as a single dose in severe
infection or Ampicillin 100 - 200mg/kg IV 6 hourly + Chloramphenicol 50 75mg/kg I.V. 6 hourly.
87
3.3.2. Fungal Meningitis
Fungal meningitis is usually caused by Cryptococcal neoformans. This is
commonly seen in immunocompromised individuals such as people with
HIV/AIDS or individuals with malignancies or on immunosuppressant drugs.
The drug of choice is Amphotericin-B and Fluconazole for at least 10 days and
followed by daily Fluconazole.
The Amphotericin-B dosage is 0.7mg/kg IV daily by slow infusion over 4 hours.
Current treatment guidelines do not support the slow dose escalation of
amphotericin B and are associated with poorer patient outcomes.
Caution
Amphotericin-B the daily dosage should not exceed 1mg/ kg for adults or
children.
Flucytosine is added at 150mg/kg/day every 6 hours for 6 weeks, but this is
associated with increased risk of bone marrow toxicity and clinical research
showed no increased benefit when compared to Amphotericin-B and
Fluconazole.
Fluconazole is also effective for cryptococcus infection, but should not be used as
monotherapy, particularly in the initial period of treatment.
Treatment of Cryptococcal Meningitis:
Amphotericin-B 0.7mg/kg IV + Fluconazole 800mg PO daily for at least 10 - 14
days, followed by daily maintenance Fluconazole 800mg for 8 – 10 weeks,
then daily chronic suppression with 200mg until CD4 count >200 for at least 6
months for HIV+ patients.
Management of intracranial pressure is essential and may require repeated lumbar
punctures to drain CSF to reduce the pressure. Children can be treated with 3 to
6mg/kg/ day.
Tuberculous meningitis may complicate pulmonary tuberculosis especially in
patients with immunodeficiency, also in children between 1 and 5 years and in the
elderly. These should be treated with anti- tuberculosis therapy, which should
be prolonged for an extra 3 months.
Supportive
Fever, dehydration, and electrolyte disorders require correction.
Care must be taken not to over hydrate patients with cerebral oedema.
Convulsion and status epilepticus are treated appropriately.
88
All patients with presumed bacterial meningitis (of unknown aetiology) should
be isolated for the first 24 hours of therapy.
Viral meningitis may complicate viral infection in other parts of the body e.g.
herpes meningitis. Most common causes of viral meningitis or encephalitis are
herpes viruses.
Human Herpes Virus (HHV3 or Varicella Zoster Virus): commonly causes
Chickenpox or shingles. If you suspect a VZV meningitis or encephalitis:
Acyclovir IV 10mg/kg q8 hours for 14 - 21 days in adults, but can use higher
doses in neonates up to 20mg/kg IV q8hrs to reduce rates of relapses. Oral
Acyclovir should not be used, as therapeutic levels will not be achieved. Children
5mg/kg 8 hourly.
Prevention
•
•
3.4.
Avoid overcrowding
Immunisation against Meningococcal Meningitis.
ANTHRAX
Description
This is a highly infectious disease of animals especially ruminants, transmitted
to man by contact with the animal or animal products (carcasses) or faeces. The
causative organism, Bacillus anthracis is a large gram-positive, facultatively
anaerobic, encapsulated rod. The spores are resistant to destruction, remaining
viable in soil and animal products for decades.
Human infection is usually through the skin but has occurred following ingestion of
contaminated meat. Inhalation of spores under adverse conditions (e.g. the
presence of acute respiratory infection) may result in pulmonary anthrax (wool
sorter’s disease) which is often fatal.
Clinical Features
The occupational history of the patient is often important. The incubation period
varies from 12 hours to 5 days.
The cutaneous form: begins as a red-brown papule that enlarges with
considerable peripheral erythema, vesiculation, and induration. Central
ulceration follows, with serosanguineous exudation and formation of a black
eschar. Local lymphadenopathy may be seen; occasionally fever, malaise,
nausea, vomiting, myalgia and headache.
Pulmonary Anthrax:
89
This follows the rapid multiplication of spores in the mediastinal structures.
Serosanguineous transudation, pulmonary oedema, and pleural effusion
occur. Initial symptoms are insidious and resemble influenza. Fever
increases, within a few days and severe respiratory distress, develop. Chest
x-ray may show diffuse patchy infiltration; the mediastinum is widened
because of enlarged haemorrhagic lymph nodes.
Treatment
Treatment is mainly by an antibiotic, penicillin is the antibiotic of choice: –
Procaine penicillin-G 600, 000 unit I.M twice daily for 7 days prevents the
systematic spread and induces gradual resolution of the pustule
OR
Tetracycline 2g per day in 4 divided doses for seven days
OR
Erythromycin at 500mg 6 hourly is a good alternative in children or
pregnancy for seven days.
For pulmonary anthrax: Early and continuous I.V. therapy of
Benzylpenicillin 20MU per day may be life-saving.
If treatment is delayed (usually because the diagnosis is missed), death is
likely to occur.
Prevention
A vaccine is available for those at high risk (veterinarians, laboratory
technicians, butchers and employees of textile mills processing goat hair);
advocating the use of personal protective equipment, gloves, overalls, boots
should be encouraged.
3.5.
SEXUALLY TRANSMITTED INFECTIONS (STI)
Sexually Transmitted Infections (STIs) are among the most common causes of all
Out Patient Department (OPD) attendances in Zambia.
There are three approaches to the management of STIs,
i)
ii)
iii)
Aetiological: - where one collects specimens for laboratory
identification of causative agent before treatment.
Clinical: - where one depends on experience and own knowledge, and
Syndromic: - where one identifies based on symptoms and signs and
treats to cover the majority of organisms that may cause those symptoms.
90
The syndromic approach to managing STIs has been adopted by the Ministry of
Health for the management of STIs in public health institutions in Zambia.
Syndromic case management is based on identifying consistent groups of
symptoms and easily recognized signs and providing treatment which will deal
with the majority of organisms responsible for producing each syndrome. Using
the syndromic approach, a diagnosis is made by taking a client's history and
examining them to verify their STI problem.
There are 8 common syndromes namely:
•
•
•
•
•
•
•
urethral discharge
vaginal discharge
genital ulcer
genital growth
lower abdominal pain
inguinal bubo
scrotal swelling and
• neonatal conjunctivitis.
Urethral Discharge
This is a condition in which there is dysuria coupled with often copious, mucoid
discharge from the urethral meatus. Two common conditions presenting with
urethral discharge are Gonococcal urethritis.
3.5.1.
Gonococcal urethritis
Description
This is an acute inflammatory condition of the columnar epithelial lining of the
urethra. It is caused by a gram- negative intracellular diplococcus, Neisseria
gonorrhoea.
Clinical Features.
The incubation period is 3 to 5 days and the patient will present with dysuria
(difficulty in micturition), followed by urethral discharge of copious, a mucoid
fluid which sometimes contains puss. Frequency and urgency may develop as the
disease spreads to the posterior urethra. Examination of the discharge shows a
purulent, yellowish-green urethral discharge. The lips of the meatus may be red
and swollen.
Complications
These include:
91
Acute epididymo-orchitis: This is an important complication, which is usually
unilateral swelling and tenderness of the testis and epididymis. Bilateral
epididymo-orchitis may result in sterility.
Urethral strictures: This is a late complication occurring in cases which are treated
inadequately or not at all. This could occur 10 to 25 years after initial infection or
in cases of recurrent infections.
Disseminated Gonococcal Infection: This is an arthritis-dermatitis syndrome in
which the patient presents with a mild febrile illness, malaise, migratory
polyarthralgia or polyarthritis) and a few pustular skin lesions.
3.5.2. Non-Gonococcal Urethritis
Description
The term Non-gonococcal urethritis is used to describe other causes., of
urethritis apart from Neisseria gonorrhoeae. The organisms commonly
responsible are Chlamydia trachomatis and Ureaplasma urealyticum among
more than 20 known organisms.
Clinical Features
Symptoms usually occur 7 to 28 days after intercourse; usually mild dysuria and
discomfort in the urethra and a clear to purulent mucoid discharge. Although the
discharge may be slight and the symptoms mild, they are frequently more
marked in the morning when the lips of the meatus are often stuck together with
dried secretions.
On examination, the meatus may be red, with evidence of dried secretion on
underwear. Occasionally the onset is more acute, with dysuria, frequency and a
copious purulent discharge.
Diagnosis
This is based on bacteriological examination of the discharge to exclude
gonorrhoea.
Complications
These include epididymitis and urethral stricture. Perihepatitis could also occur.
92
Treatment
Syndrome
Causal
Pathogens
Recommend
ed regime
Recommended
regime
for
children
Urethral
Discharge
Neisseria
Gonorrhea
Ciprofloxaci
n 500mg
Spectinomycin
40mg/kg
IM
stat (maximum
2g stat)
stat Plus
Doxycycline
100 bd X 7/7
Chlamydia
>8years
old
Erythromycin
50mg/kg/day in
4 doses for 14
days
Persistent urethral discharge one week after treatment consider
Trichomonas vaginalis, then treatment with Metronidazole 2g PO single
dose for adults and 5mg/kg body weight for children.
Prevention
Avoiding multiple sexual partners and unprotected casual sexual
intercourse. Condom use is advised.
93
3.5.3. Gonorrhoea in Neonates
3.5.3.1. Ophthalmia Neonatorum
Description
Ophthalmia Neonatorum is inflammation of the conjunctiva in the neonatal
period (day 1 to day 28) due to infection with Neisseria gonorrhoeae. The
gonococcus produces a toxin which dissolves the cornea and can lead to blindness.
The infection is acquired during birth when passing through the birth canal. The
incubation period is 3 to 5 days.
Non-gonococcal conjunctivitis is due to Chlamydia trachomatis, Staphylococcus
aureus and Streptococcus pneumoniae.
Clinical features
It commonly presents with purulent, copious eye discharge usually in both eyes.
Itching and redness are also present The neonate may also present with septicaemia
with fever, rash and joint swelling.
Diagnosis
This is confirmed by taking an eye swab for culturing for Gonorrhea.
Treatment
Note: The use of antibiotic eye ointments in gonococcal conjunctivitis is of no
documented benefit. Systemic treatment is recommended for all symptomatic
cases
NOTE: The baby's mother and partner(s) should receive syndromic treatment for
Gonorrhea and Chlamydia.
Breastfeeding mothers should be given Gentamicin and not Ciprofloxacin for
gonorrhoea but for Chlamydia give Erythromycin.
Neonatal
Conjunctivitis
Gonorrhoea
Spectinomycin 50mg/kg
IM stat
Plus Chlamydia
Plus
Erythromycin 50mg/kg
PO QID X 7 days
94
Normal Saline lavage of
the affected eye
Prevention
Women with pelvic inflammatory disease or urinary tract infection in
pregnancy should be treated promptly before delivery. Every child’s eyes
should be swabbed with cotton wool soaked with Povidone-iodine or normal
saline immediately after birth. Apply any of the following:
•
•
•
•
•
Povidone-iodine
Silver nitrate 1% aqueous solution stat
Erythromycin 0.5% ophthalmic ointment stat
Tetracycline ophthalmic ointment 1% stat
Normal saline
Vaginal Discharge and Lower Abdominal Pain in Women
Various gynaecological conditions could present with vaginal discharge and
lower abdominal pain. These include:
•
•
•
3.5.4.
Pelvic Inflammatory Disease (PID)
Vulvovaginitis
Urinary Tract Infection (UTI)
Pelvic Inflammatory Disease
Description
Pelvic inflammatory disease is a condition involving the pelvic organs i.e.
cervix (cervicitis), uterus (endometritis), salpinx (salpingitis) and ovaries
(oophoritis).
Organisms that may be responsible for this disease are- Neisseria gonorrhoea and
Chlamydia trachomatis. Endogenous aerobic bacteria such as E. coli, Klebsiella,
Proteus and Streptococcus species and endogenous anaerobes such as Bacteroides,
Peptostreptococcus and Peptococcus; Mycoplasma hominis and Actinomycetes
isreali affect predominantly the vagina presenting as vaginal discharge but
ascend through the cervical tract to cause Pelvic Infl am mato ry Disease (PID). PID
is a disease of the young woman.
Some of the predisposing factors are:

Sexual intercourse

Induced abortion
95





Dilatation and curettage or endometrial biopsy
Intra-uterine device (IUD) insertion or use
Hyste rosalpingosramy
Laparoscopy
Radium insertion into the endometrial cavity.
Clinical Features
Symptoms

Lower abdominal pain

Copious purulent vaginal discharge may be present or absent

High -grade fever is an indicator for admission

Nausea

Vomiting

Painful sexual intercourse (dyspareunia)Signs

Occasional diarrhoea

Lower abdominal tenderness with rebound is an indicator for admission

Adnexia tenderness

Cervical excitation
Complications

Peritonitis

Tuba-ovarian abscess

Hydrosalpinx

Ectopic Pregnancy

Chronic Pelvic Pain

Infertility

Mortality
Indications for immediate referral to gynaecology or surgery

missed/overdue period

recent delivery or abortion

abdominal guarding or rebound tenderness

abnormal vaginal bleeding

abdominal mass

temperature above 38 degrees Celsius
3.5.5.
Vulvovaginitis
Description
Vulvovaginitis is an inflammatory condition affecting the vulva and the vagina.
The causative organisms include; Candida albicans, Chlamydia trachomatis,
Trichomonas vaginalis. Bacterial vaginosis.
96
Clinical Features
Symptoms:

Vaginal itching

Burning sensation
Signs
A watery, thick or mucoid, foul-smelling and yellowish or brown vaginal
discharge is sometimes present.
Diagnosis
Insert a speculum into the vagina and using a swab take two specimens one
from the cervical mucosa for gram stain and culture on Gonococcal media
for gonorrhoea, the second for wet mount and microscopy for Candida,
Trichomonas.
Complications

Secondary bacterial infection

Skin excoriation

Dermatitis
Treatment
Vaginal
Discharge
and lower
Abdomina
l Pain
Neisseria
gonorrhoeae
Adults:
Ciprofloxacin
500mg PO stat Plus
Doxycycline 100 bd
PO X 7/7
Children:
Spectinomycin
40mg/kg IM stat
(maximum 2g stat)
>8years
old
Erythromycin
50mg/kg/day in 4
doses for 14 days
Plus
Chlamydia
Metronidazole 2g
PO stat
Trichomoniasis
Plus
Bacterial
Vaginosis
97
Metronidazole
5mg/kg
body
weight
Vaginal
Candidiasis
3.5.6.
Fluconazole
150mg PO stat
Urinary Tract Infection
(refer to Chapter 3.5 on STI)
Genital Ulceration
Description
Genital Ulceration is the loss of continuity in the epithelial surface covering the
genital area.
Ulcerative lesions of the genitalia are common outpatient problems. Men are
more commonly affected than women. There are many causes including:





3.5.7.
Chancroid
Granuloma inguinale (Donovanosis)
Herpes genitalis
Lymphogranuloma venereum
Syphilis
Syphilis
Description
This is an infection caused by spirochaetes called Treponema pallidum, a
corkscrew-shaped organism with an incubation period of 9 to 90 days.
Clinical Features
Primary syphilis presents with a painless papule at the site of inoculation which
then ulcerates. The ulcer called a chancre, is often solitary with a firm, indurated
base and is therefore often referred to as hard sore. Oral and vulva lesions may be
subtle. In men, the chancre could be found on the glans penis, shaft, anus and
rectum whereas in women it is found on the vulva, cervix and perineum.
Chancres may also be found on the skin or mucous membrane of the
anogenital area as well as the lips, tongue, buccal mucosa, tonsils or fingers.
Rarely chancres can be found on other parts of the body, often producing such
minimal symptoms that they are ignored. There may be bilateral inguinal
lymphadenopathy. Without treatment, the ulcer heals in 3-6 weeks.
98
Secondary syphilis presents 6 to 12 weeks after infection with cutaneous rashes
which may be generalized and also affect the soles and palms. The rash can
mimic any skin disease ranging from circular plaques like psoriasis, or light copper
coloured scaly macules like pityriasis rosea Patchy hair loss is a common
presentation. In the mouth are found snail track ulcers which are slimy superficial
erosions. Condylomata lata is flat warty papules and plaques found on the
genitalia and perineal skin. Generalised enlarged lymph nodes may occur.
Other areas may be involved as well such as eyes (uveitis), bones (periostitis),
joint s, meninges, kidneys (glomerulitis), liver and spleen.
Tertiary syphilis: Presents 10 to 25 years after t heinitial infection. The patient may
present with cardiovascular complications. These include dilated aneurysm of the
ascending aorta, narrowing of the coronary aorta or aortic valvular insufficiency.
The central nervous system complications include dementia and psychosis and
meningovascular neurosyphilis.
Congenital syphilis presents with clinical features as those of secondary syphilis
in adults. Mild constitutional symptoms of malaise, headache, anorexia, nausea,
bone pain s and fatigability are present as well as fever, anaemia, jaundice,
albuminuria and neck stiffness.
Diagnosis
Collect blood specimen and allow to clot, send to the laboratory for identification
of antibodies to Treponema pallidum using screening methods like VDRL (Venereal
Disease Research Laboratory), RPR (Rapid Plasma Reagin)
Treatment
Adult:
Benza thine Penicillin 2.4 M. U IM weekly for a total 3 doses Alternatively give
Procaine Penicillin 1.2 M.U IM daily for 10 days
OR
Erythromycin 500mg 4 times a day for 14 days in penicillin allergy and
children (50mg/kg body weight )
OR
In non-pregnant adults; Doxycycline 100mg twice daily for 14 days.
Child:
Benzathine Penicillin 50 000units/kg IM weekly for a total of 3 doses.
Treatment of Genital Ulcers
99
Most patients with primary or secondary syphilis infection have jarisch - 1erxheimer reaction within 6 hours to 12 hours of initial treatment. The reaction
is manifested by generalized malaise, fever, headache, sweating, rigours and a
temporary exacerbation of syphilitic lesions. This usually subsides within 24 hours
and poses no danger other than the anxiety it produces.
3.5.8.
Chancroid
Description
This is an acute, localized, contagious disease characterised by painful genital
ulcers and suppurative inguinal lymph nodes. The causative organism is
Haemophilus ducreyi a short, slender, gram-negative bacillus with rounded ends
and usually found in chains or groups.
Clinical Features
The incubation period is 3 to 7 days. Small, painful papules rapidly break
down to become shallow ulcers with ragged undermined edges. The ulcers,
which vary in size and often coalescing, are shallow, non-indurated, painful and
surround ed by a reddish border. The inguinal lymph nodes become enlarged,
tender and matted, forming a fluctuant abscess (Bubo) in the groin. The skin over
the abscess becomes red and shiny and may break down to form a sinus. Chancroid
may coexist with other causes of genital ulcer.
Complications

Phimosis

Urethral stricture

Urethral fistula
Severe tissue destruction leading to a phagedenic ulcer which may grow rapidly and
cause auto amputation of the penis. Biopsy the ulcer to distinguish from
squamous cell carcinoma.
Treatment
Ciprofloxacin 500mg twice daily orally for three days.
OR
Erythromycin 500mg orally 6 hourly for 7 days
3.5.9. Lymphogranuloma Venereum
Description
This is characterized by transitory primary ulcerative lesion followed by
suppurative lymphadenitis. It is caused by serotypes of Chlamydia trachomatis L1,
100
L2, L3 which are distinct from those causing trachoma, urethritis, cervicitis and
inclusion conjunctivitis.
Clinical Features
The incubation period is 3 to 12 days. A small, transient, non-indurated
vesicular lesion is formed that rapidly ulcerates, heals quickly and may pass
unnoticed. Usually, the first symptoms are unilateral, tender enlarged
inguinal lymph nodes, enlarging above and below the inguinal ligament
giving rise to the characteristic groove sign. They progress to form a large,
tender fluctuant mass that adheres to the deep tissues and inflates the
overlying skin. Multiple sinuses may develop and discharge purulent or
bloodstained material. Healing eventually occurs with scar formation. The
patient may have constitutional symptoms of fever, malaise, joint pain,
anorexia, and vomiting. Backache is common in women in whom the lesion
may be on the cervical or upper vagina resulting in the enlargement and
suppuration of perirectal and pelvic lymph nodes. This results in the
formation of rectovesical and rectovaginal fistulas. Aspirate suppurating
glands with a wide bore needle through intact skin. Avoid incision and
drainage through a fluctuant area which results in chronic sinus formation.
Treatment
Drugs
Doxycycline 100mg orally twice daily for 14 days or
Alternative and/or in pregnancy
Inguinal Buboe
Chancroid
Ciprofloxaci
n 500mg PO
BDX3 days
Erythromycin 500mg orally 6 hourly for 14 days.
Lympho granuloma
All sexual partners should be examined. The patient should be kept under
Doxycycli
observation for 6 months after apparently successful treatment.
ne 100 BD XVenerium
14days
3.5.10. Herpes Genitalis
Description
101
Herpes Genitalis is an infection of the genital or anogenital area by herpes
simplex virus (herpesvirus hominis type 2). Type 1 (HSV-1) is the most
common cause of genital ulceration in developed countries. It is moderately
contagious and usually spreads by sexual contact. Lesions usually develop
4 to 7 days after sexual contact. The condition tends to recur because the
virus establishes a latent infection of the sacral sensory nerve from which it
reactivates and re-infects the skin.
Clinical Features
The primary lesions are more painful, prolonged and widespread than those
of recurrent infections. Itching and soreness usually precede a small patch
of erythema on the skin or mucous membrane. A small group of painful
vesicles develops, they erode and form several superficial, circular ulcers
with a red areola, which coalesce.
The ulcers become crusted after a few days and generally heal with scarring
in about 10 days. The inguinal lymph nodes are usually slightly enlarged.
Tender lesions in men may occur on the prepuce, glans penis, and penile
shaft whereas in women may occur on the labia, clitoris, perineum, vagina
and cervix. In addition to pain, in primary infection, the patient may
experience generalized malaise, fever, difficulty in micturition or
difficulties in walking.
Diagnosis
This is mainly clinical but can be confirmed by tissue culture.
Scrape the roof of the blister and make a smear. Stain with Papanicolaou
stain. Giant multinucleated cells are diagnostic
Complications
 Aseptic meningitis
 Transverse myelitis
 Autonomic nervous dysfunction involving the sacral region leading to
urinary retention.
Drugs
Acyclovir 200mg orally 5 times daily for 7 days for initial infection.
Acyclovir 200mg orally 5 times daily for 5 days for recurrent infection.
102
Genital Ulcer
Disease
Syphilis
Benzathine
Penicillin 2.4M.U
IM weekly x 3
doses
Benzathine Penicillin 50
000units/ kg IM weekly
x 3doses
Ciprofloxacin
Chancroid
Herpes Genitals
Lympho
granuloma
Venerium
500mg PO BD x days
Acyclovir 400mg
TDS x 7 days
Doxycycline 100
BD x 14days
103
Acyclovir 20mg/kg 8
hourly for CNS and
disseminated disease;
extend therapy to 21days;
for disease limited to
the skin and mucous
membranes for 14 days
3.5.11. Granuloma lnguinale (Donovanosis)
Rare in Zambia
Description
This is a chronic granulomatous condition usually involving the genitalia
and spreads by sexual contact. It is common in the tropical and subtropical
climate and is caused by gram-negative, Calymmatobacterium granulomatis
and intracellular bacillus found in mononuclear cells.
Clinical Features
The initial lesion is a painless, beefy-red nodule. Multiple nodules appear
and coalesce to form a large elevated, velvety, granulomatous mass. The
incubation period is 1 to 12 weeks. The sites of infection in men are penis,
scrotum, groin and thighs, whereas in women the vulva, vagina and
perineum are the common sites, with the face being affected in both sexes.
In homosexual men, the anus and buttocks are affected. There is no
lymphadenopathy. The infection may involve other parts of the body.
Progress is slow but the eventual lesion may cover the whole external
genitalia, the deep-seated ulcers causing lymphatic obstruction and
elephantiasis of the genitalia. Healing is also slow and often leads to scar
tissue formation. Secondary infection is common and can cause gross tissue
destruction.
Complications
• Anaemia
• Weight loss
Diagnosis
Do a punch biopsy of the lesion and crush between two glass slides. Stain
with Wright's or Giemsa Stain to show gram-negative rods within
macrophages. Secondly, send the biopsy for histopathology to rule out
squamous cell carcinoma. Thirdly, diagnosis can be based on clinical
findings that are often characteristic i.e. bright, beefy- red granulomatous
lesions.
Treatment
Drugs
• Erythromycin 500mg orally 6 hourly for 14 to 21 days.
Prevention:
•
Condom use is advisable
104
3.5.12. Genital Growth (Condylomata Acuminata)
Description
This is a fleshy growth found around the anogenital region caused by
Human papillomavirus infection HPV6 and 11 but HPV 16 and 18 are
associated with cancer of the cervix.
Clinical Features
Lesions can be subclinical (not visible to the naked eye) or overt anogenital
warts.
Visual inspection of overt disease (fleshy growth of the lower genital tract)
detects obvious lesions, which are often multifocal in distribution. However,
the appearance and size depending on their location, the trauma to which
they are subjected and the degree of irritation.
Genital
growths
Genital
warts
(Condylomata
Acuminata)
Podophyllin
25% topically
by physician
weekly
till
resolved
Benzathine Penicillin
2.4 MU IM weekly
for 3 doses
Condylomata lata
Cauterisation
(i)
0
5
–
fluorouracil cream
(ii)Trichloroacetic
acid
(iii)Cryosurgery
(iv)
Electro
cauterisation
(v)
Laser
vapourisation
(vi)
Surgical
removal
Benzathine
Penicillin
50
000iu/kg IM weekly
for 3 doses
For Cervical Warts DO NOT CAUTERISE
Diagnosis
This is based on direct inspection. If uncertain, confirmation can be done by
biopsy. May predispose to cancer of the cervix.
Treatment
Podophyllin paint compound (Podophyllin resin 15% in compound Benzoin
tincture) – applied every week until lesions disappear. The application
should not be left on for more than 4 hours. Where possible, the application
should be done in the clinic.
OR
105
Silver nitrate crystals 5% daily until lesions disappear. Recurrence is
common.
Prevention
Avoid multiple sexual partners.
Condom use is advised.
Special consideration pertaining to syndromic management.
Pregnant women
•
•
•
•
Vaginal discharge syndrome: for Neisseria gonorrhoeae give
Spectinomycin 2g IM stat; for Chlamydia give Erythromycin
500mg QID for 5-7 days
Genital Ulcer Disease: for Chancroid give Erythromycin 500mg
QID X 7 days; for LGV give Erythromycin 500mg QID for 7 days;
for Herpes Genitalis give Acyclovir as in the non-pregnant. In the
event of an outbreak during labour, consult a gynaecologist to
consider an emergency Caesarian Section; for Donovanosis give
Erythromycin 500mg QID for 3 weeks until all lesions have
completely healed.
Genital Growths: Genital warts, LEAVE ALONE, wait until
delivery, then decide on surgical management. During labour, if the
pelvic outlet is obstructed, or vaginal delivery would result in
excessive bleeding, Caesarian Section is indicated. For cervical
warts, refer to a gynaecologist for a pap smear to rule out CIN,
because cauterization can lead to vaginal fistulas or perforation. For
anal warts, refer to a surgeon because cauterization could lead to
fistula formation. For urethral-meatal warts, refer to a surgeon
HIV Infected
Genital Ulcer Disease: in Chancroid, since the ulcers heal slower, it
is recommended that the courses of treatment take longer, give
Erythromycin 500mg QID for 5 - 7 days.
Children
For children treated with Erythromycin, follow up for symptoms of pyloric
stenosis which present with vomiting and abdominal discomfort/distention.
3.5.13. Hepatitis
Description:
Acute inflammation of the liver caused by primarily human viruses from A
to E; B and C.
Mode of transmission
106





Cutaneous, or
Mucous membrane exposed to contaminated blood
Unprotected sex by an infected partner, or through
Contaminated needle by injection, and
Perinatal transmission.
The clinical features of acute hepatitis are common to all of them and these
are:









Malaise
Nausea
Abdominal pain
Anorexia
Jaundice
Dark urine
Fever
Rash
Arthralgia
107
Hepatitis B
Hepatitis C
Incubation
60 – 180 days
15 – 180
days
Transmission
Blood borne Sexual
Blood
Sexual
Occasionally varies by age
Usually
Etiologic agent
Hepatitis B Virus
Hepatitis C Virus
Comments
Vaccine available
Not available
Serologic diagnosis
HBsAg, IgM anti-HBc
HCV RNA; anti H
V
C
Progression
chronicity
to
borne
Treatment
Counsel patient for HIV AIDS and if negative give Lamivudine 150mg twice a
day.
If positive refer to ART Clinic.
Prevention
•
•
•
Hepatitis B vaccine is available for children, but no vaccine for Hepatitis C
Safe sex
Avoid the use of contaminated needles.
3.5.14. Acute Epididymo-orchitis
Description
This is an inflammation of the epididymis and the testes. It is usually a
complication of urethritis which is not treated at all or which was improperly
treated.
Clinical Features
Presentation is mucoid, puss-filled urethral discharge, painful scrotal swelling
usually unilateral but could be bilateral, the pain is gradual and dull. Milking of
the urethra produces puss-filled discharge. Diagnosis is confirmed by culture of
urethral discharge. Complications include atrophy of the testes, infertility.
108
Supportive
•
•
•
•
Bed rest,
Scrotal support or elevation,
Scrotal ice packs,
Ana lgesia
The causative organism in men less than 35 years of age is usually Neisseria
gonorrhoeae or Chlamydia trachomatis.
Treatment
Drugs
The best antibiotics are those that are sensitive to the above organisms.
Ciprofloxacin 500mg stat oral + Doxycycline 100 mg OD for 7 days.
OR
Ceftr iaxone 1g (I.M.) once + Doxycycline 100mg 12 hourly for 7 days.
Erythromycin may be substituted for Tetracycline or Doxycycline at 500mg
every 6 hours for 7 days.
In men older than 35 years of age, the cause is mostly due to coliform gramnegative bacilli. Gentamicin 80mg 8 hourly for 7 days or a 3rd generation
cephalosporine as above may be used until the sensitivity is determined.
Prevention


Avoiding multiple sexual partners
Usage of condoms.
3.5.15. Urinary Tract Infection
Description
This is an infection, often bacterial, of the ureters, bladder and urethra. Urinary
tract infection occurs much more frequently in women than in men, especially in
pregnancy.
Most urinary tract infections are commonly caused by gram-negative bacteria,
including E. coli, Klebsiella species, and Proteus species. Less commonly caused
by gram-positive cocci such as Staphylococcus species (especially non-coagulase
Staphylococcus, and Enterococci.
109
Clinical Features
In general, symptomatic urinary tract infections are characterised by irritative
symptoms of the urinary bladder i.e.
•
•
•
Frequency,
Urgency and
Dysuria (pain on passing urine).
Urinary tract infections may also be asymptomatic and diagnosis is coincidental
on testing the urine and possibly culture of the urine.
Predisposing factors to urinary tract infections include catheterisation, colposcopy,
cystoscopy and following intravenous urogram (I.V.U).
Complications
These include:
•
•
•
Chronic pyelonephritis
Prostatitis in men
Acute epididymo orchitis
Diagnosis
This is made by history, physical examination and laboratory investigations.
Midstream specimen (MSSU) urine is collected for microscopy, culture and
sensitivity. The diagnosis is based on colon count of bacteria of more than 10/5/ml
on culture.
Treatment
This should be instituted based on the common cause of UTI. Treatment should be
reviewed as soon as the sensitivity results are ready.
Drugs
Based on sensitivity:
Nitrofurantoin 50 - 100mg 12 hourly for 5 to 7 days
OR
Nalidixic Acid 250mg 8 hourly for 5 days
If there are complications these drugs are used for at least 14 days or more.
Refer repeated infections to a higher level.
Supportive
110
Increase water intake, prophylactic antibiotic therapy for those who have multiple
repeated urinary tract infection or those who have a congenital abnormality of the
urinary tract predisposing them to multiple repeated infections before surgical
correction of such abnormality.
3.5.16. Acute Pyelonephritis
Description
This is a bacterial infection of the kidney and renal pelvis, often bilateral.
Escherichia coli is the commonest bacteria isolated, others include Klebsiella sp,
Proteus mirabilis, Enterobacter, also Enterococcus and Staphylococcus aureus.
Clinical Features
Pyelonephritis is especially common in girls or pregnant women and after
bladder catheterization or instrumentation. It is not common in men who are free
from urinary tract abnormalities.
Typically, the onset is rapid and characterised by chill s, fever, loin pains, nausea,
and vomiting. Symptoms of lower urinary tract infection, including frequency,
dysuria occur concomitantly in a third of patients. Physical examination
reviews some abdominal rigidity especially in the loin of the infected side.
In children, symptoms often are slight and less characteristic.
Diagnosis
Diagnosis is made by urinalysis, microscopy, culture and sensitivity. On
urinalysis, the pH may be alkaline because of the urea-splitting organism,
proteinuria is minimal. White blood cells (WBC) greater than 10/ ml are usually
found in fresh uncentrifuged urine, and haematuria is common. Culture usually
shows greater than 7 04 colony forming units (CFU)/ ML. On microscopy,
presence of microscopic casts, WBC greater than 70/ ml are usually found per High
Power Field (HPF).
Complications
These include chronic pyelonephritis, chronic renal failure.
Treatment
Initial treatment can be oral for those less ill but will be parenteral for most
patients. After 24 to 48 hours without fever, most patients receiving I.V therapy
can be switched to oral regimes.
In uncomplicated cases a single agent may be used:
• Amoxycillin tablets 250mg - 500mg 8 hourly for Ad ults
• Ciprofloxacin tablet 500mg - 1gm 12 hourly Adult for 14 days.
• Cefotaxime 1g 12 hourly for 14 days
111
•
•
3.6.
Ceftriaxone I.V. 1gm once daily for 14 days
Most treatments are used for 2 weeks, but up to 6 weeks may be required
to prevent relapse.
THE PLAGUE
Description
This is an acute, severe infection appearing in, bubonic, septicemic or
pneumonic form, but pharyngeal and meningeal could also be found. This
is caused by a bacteria called Yersinia pestis; a short bacillus that often shows
bipolar staining (especially with Giemsa stain). Plague often occurs primarily in
rodents e.g. rats. Plague is transmitted from rodent to man by the bite of an
infected flea vector. Man to man infection occurs through inhalation of droplets in
pneumonic plague. Septicaemia and meningeal plague are due to haematological
spread.
Clinical Features
Symptoms
•
•
•
•
•
•
•
•
Headache
Severe malaise
Vomiting
Chills
Muscle pain
Cough
Abdominal pain
Chest pains
3.6.1. Bubonic Plague
This is the commonest form. The incubation period varies from a few hours to 12
days but is usually 2 to 5 days. Onset is abrupt often associated with chills,
fever, rapid pulse with low blood pressure (hypotension) may occur. Enlarged
lymph nodes (buboes) appear very shortly before the fever. The femoral and
inguinal lymph nodes are most commonly involved; followed by axillary cervical
or multiple nodes. Typically, the nodes are extremely tender and firm,
surrounded by considerable oedema. The liver and the spleen may be palpable.
The mortality rate of the untreated patient is about 60%.
112
3.6.2.Primary Pneumonic Plague
This has 2 to 3 days incubation period, followed by abrupt onset of high fever,
chills, tachycardia and headache, often severe. Cough is not prominent
initially. Cough develops within 20 to 24 hours with the sputum, mucoid at
first, and rapidly becomes bloody.
Chest X-ray shows progressive pneumonia. Most untreated patients die within 48
hours of the onset of symptoms.
Diagnosis is based on the recovery of the organisms which may be isolated
from blood, sputum or lymph node aspirate. Needle aspiration of bubo is
preferable since surgical drainage may disseminate infection. Inject sterile
Phosphate buffered saline in the bubo and aspirate the pus.
Treatment
Drugs
Uncomplicated plague
Treatment in Adults
• Streptomycin 15mg/kg 12 hourly for 10 days or Gentamicin 5mg/kg IM or
IV qid or Doxycycline 100mg po bid or Chlorampeni col 25mg/kg IV qid
• Tetracycline 250mg -1g orally 6 hourly for 7 to 10 days or
• Chloramp henicol 25mg/kg I.V or orally 6 hourly for 7 to 19 days.
Treatment in pregnancy
• Gentamycin 5mg/kg IM
• Doxycycline 100mg PO bid
Treatment in children
• Streptomycin 15mg/kg IM BID
• Gentamycin 2.5mg/kg IM
• Doxycycline 2.2mg/kg IV BID
• Chlorampenicol 25mg/kg IV QID
Prevention
This is based on rodent control and the use of repellent to minimize fleabites. Through
immunization with standard killed plague vaccine gives protection to at-risk
individuals e.g. veterinary doctors.
113
3.7. HUMAN IMMUNODEFICIENCY VIRUS (HIV) AND ACQUIRED IMMUNE
DEFICIENCY SYNDROME (AIDS)
Description
HIV: Human Immunodeficiency Virus. This is the virus that causes HIV infection and
AIDS.
AIDS: Acquired Immune Deficiency Syndrome AIDS is the severest stage of the
clinical spectrum of HIV infection. It occurs when the immune system of a person
who is HIV- infected becomes so suppressed that they are vulnerable to
opportunistic infection and neoplasms.
ART: Antiretroviral Therapy. A combination of antiretroviral drugs used in the
management of HIV/AIDS
Clinical Features
The WHO clinical staging is used to determine the severity of HIV infection based on
the presenting opportunistic infections in a confirmed HIV infected individual.
WHO staging can be used to make decisions for switching or stopping ART.
WHO Clinical Staging of HIV disease in Adults and Adolescents
CLINICAL STAGE 1
• Asymptomatic
• Persistent generalized lymphadenopathy
CLINICAL STAGE 2
• Moderate unexplained weight loss (under 100/o of presumed or measured body
•
•
•
•
•
•
weight)
Unexplained refers to where the condition is not explained by other conditions
e.g. nutrition or exercise regime intended to lose weight.
Assessment of body weight among pregnant women needs to consider the
expected weight gain of pregnancy.
Recurrent upper respiratory tract infections (sinusitis, tonsillitis, otitis media,
pharyngitis)
Herpes zoster in the last 5 years
Angular cheilitis
Recurrent oral ulceration
Papular pruritic eruptions
Seborrhoeic dermatitis
114
• Fungal nail infections
CLINICAL STAGE 3
• Unexplained severe weight loss (over 100/o of presumed or measured body
•
•
•
•
•
•
•
•
weight) Assessment of body weight among pregnant women needs to consider
the expected weight gain of pregnancy.
Unexplained chronic diarrhoea for long er than one month
Unexplained persistent fever (intermittent or constant for longer than one
month)
Persistent oral candidiasis
Oral hairy leukoplakia
Pulmonary tuberculosis
Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or
joint infection, meningitis, bacteraemia)
Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
Unexplained anaemia (below 8 g/dl), neutropenia (below 0.5 x 109/ I) and/or
chronic thrombocytopenia (below 50 x 109 / l)
CLINICAL STAGE 4
• HIV wasting syndrome (>10% weight loss and > 1-month diarrhoea and > 1month fever)
• Pneumocystis pneumonia
• Recurrent severe bacterial pneumonia
• Chronic herpes simplex infection (orolabial, genital or anorectal of more than one
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
month's duration or visceral at any site)
Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
Extrapulmonary tuberculosis
Kaposi sarcoma
Cytomega lo virus infection (retinitis or infection of other organs)
Central nervous system toxoplasmosis
HIV encephalopathy
Extrapulmonary cryptococcosis including meningitis
Disseminated nontuberculous mycobacterial infection
Progressive multifocal leukoencephalopathy
Chronic cryptosporidiosis
Chronic isosporiasis
Disseminated mycosis (extrapulmonary histoplasmosis, coccidiomycosis)
Recurrent septicaemia (including non-typhoidal Salmonella)
Lymphoma (cerebral or B-cell non-Hodgkin)
Invasive cervical carcinoma
Atypical disseminated leishmaniasis
115
• Symptomatic HIV-associated nephropathy or HIV- associated cardiomyopathy
*Note: This is based on the 2020 Zambia Consolidated HIV Guidelines. HIV
treatment may be revised or changed as the disease evolves or new evidencebased national recommendations are released.
Diagnosis
• Early Diagnosis (DNA- PCR)
• HIV Self-Testing (HIV-ST)

•
•
•
•
HIV-ST is a process in which a person collects their oral fluid or blood and
then performs an HIV rapid test and interprets the result. An HIV self-test
is a screening test which requires further testing and confirmation for any
reactive result. Health care providers should ensure that users receive clear
information on:
(i) How to perform the test and interpret the result correctly
(ii) Where to access HTS and further support services
(iii) How to safely dispose of the used test-kits
(iv) The ethical and legal obligations (no one should test a third party
without their consent)
Universal Routine HIV Testing gives an opportunity to provide
immediate treatment and care to all HIV infected individuals through the
“test and treat” strategy without using CD4 as eligibility criteria for HIV
treatment.
Health care workers are therefore mandated to offer routine HIV testing
to all individuals presenting to health facilities (in the inpatient
department, routine testing should be extended to the caregivers).
Rapid antibody detention
i. Screening test - Determine test
ii. Confirmation test - Unigold test
iii. Tiebreaker test – Bioline test.
For children <24 months old who are breastfeeding, the mother should be
tested first. If she is HIV-positive, perform a Nucleic Acid Test (NAT)
which can be done using either a Dried Blood Spot- DBS (by being sent
to a central testing lab) or a Point-of-care machine (POC) on the HIVexposed infant (HEI), regardless of age. Infants who have HIV detectable
by NAT at birth are likely infected in utero, will progress to disease
rapidly, and, in the absence of treatment, will experience high mortality
in the first few months of life. Infants infected at or around delivery may
not have virus detectable by NAT for several days to weeks. The ability
of NAT to detect the virus in the blood may be affected by ARV drugs
taken by the mother or infant for postnatal prophylaxis, resulting in falsenegative results. This includes drugs present in breast milk as a result of
maternal ART during breastfeeding.
The rationale behind this recommendation is that infants who are first
identified as HIV-exposed postpartum have a high cumulative risk of
already having acquired HIV by the time prophylaxis is initiated; thus
NAT should be performed around the time of initiating prophylaxis,
116
which would be at birth. This will help to minimize the risk of
development of resistance because of extended prophylaxis in infected
infants and help to promote linkage to timely initiation of cART.
Clinical Management
Full History
History of the presenting complaint
ICF for TB (Cough, Fever, Weight loss and night sweats HIV history
HIV Risk factors
Past medical history Social history
Drug history
Reproductive history
Full Physical Exam
Baseline Laboratory investigations
•
•
FBC (Hb, Hct), CD4, ALT, Creatinine (CrCl)
CD4 count, HBsAg (if not vaccinated), Pregnancy test (Adolescent or woman
of reproductive age), Syphilis test (adolescent or adult), Cholesterol and
triglycerides (if starting on a PI)
• HPV test or visual inspection with acetic acid (sexually active adolescent or
woman)
• BP, BMI, RBS & Urinalysis
Eligibility Criteria for initiating ART
Prior to initiating ART in all patients ensure that:
1. HIV positive test confirmed and post-test counselling done
2. Documented treatment preparation is completed
3. Disclosure is documented
4. Minimum baseline laboratories are completed: CD4, ALT, Creatinine,
Hct/Hgb, etc.
5. Absence of the danger signs of unresolved Opportunistic Infections (Ols)
listed below is documented
a. Persistent fever
b. Persistent cough
c. Severe persistent headache
d. Anaemia (Hgb <8 or Hct <24)
e. Weight loss >10%
If ANY of the above five symptoms are PRESENT then investigate and treat as
appropriate (see the review of undiagnosed Ols on next page)
6. Initiate diagnosis with sputum for AFB, CXR, cryptococcal antigen, and
117
oxygen saturation
7. Based on test results initiate appropriate therapy
8. Initiate ART two weeks after documented response to OI treatment
9. If no clear diagnosis obvious from a diagnostic test, then consult an HIV
Specialist before initiating ART.
Zambian recommendations for initiating antiretroviral therapy in adults and
adolescents with documented HIV infection is “TREAT ALL” irrespective of
CD4 count or WHO staging.
Conditions to initiate ART irrespective of CD4 count
Condition
Recommendation
HIV positive partner in Treat all irrespective of CD4
count
Discordant Couple (see below)
Hepatitis B Virus Infection
(chronichepatitis B)*
*Patients testing HBsAg positive with CD4 counts greater than 350cells/mm3
should have ALT or AST checked and if elevated initiate ART. For patients with
normal baseline ALT or AST recheck ALT or AST and HBsAg in 6-12 months.
*If ALT or AST are elevated, or persistent HBsAg then start ART regardless of CD4
count or WHO stage. If signs of liver cirrhosis are positive HBsAg start HAART
regardless of ALT or AST values.
For patients eligible for ART provide the following risk reduction:
•
•
•
•
Finish reduction
Treat presenting problem
Identify latent opportunistic infections e.g. screen for TB
Provide Cotrimoxazole prophylaxis 960mg tablet daily (800mg Sulphadoxine +
160mg Trimethoprim)
• Provide close follow up of patient on ART in the first 2 weeks, after one month and
every 3-months
• Conduct laboratory investigations.
3.7.1.
Pre-Exposure Prophylaxis (PrEP)
Pre-exposure prophylaxis, or PrEP, is when people at high risk for HIV take HIV
medicines daily to lower chances of getting infected.
PrEP involves the use of antiretroviral (ARV) drugs before HIV exposure by
people who are not infected with HIV to block the acquisition of HIV. WHO
recommends oral PrEP containing Tenofovir (TDF) with either Emtricitabine
(FTC) or Lamivudine (3TC) to be offered as an additional prevention choice for
118
people at substantial risk of HIV infection as part of combination HIV prevention
approaches.
Considerations for PrEP
• The combination of TDF+XTC (Emtricitabine or Lamivudine) is active
against Hepatitis B infection thus discontinuation of TDF+XTC requires
close monitoring in those infected with Hepatitis B due to the concern for
rebound viremia.
• Persons with osteopenia/osteomalacia/osteoporosis may be at risk of bone
loss associated with TDF.
• PrEP efficacy has not yet been established in pregnancy and breastfeeding,
therefore its use in this population is NOT recommended.
• TDF should not be co-administered with other nephrotoxic drugs, e.g.
aminoglycosides.
• Standard TB medication does not interact with PrEP drugs and there is no
need for dose adjustments.
• Clients on MDR-TB medications may have increased risk of renal side
effects. PrEP should therefore be avoided.
• Other prevention methods should be recommended and PrEP screening
should be delayed until the end of MDR-treatment.
• Standard hormonal contraception does not affect PrEP effectiveness, nor does
PrEP affect contraceptive effectiveness.
• PrEP clients must be routinely tested for HIV infection, and cART offered
immediately if the PrEP user seroconverts.
• PrEP is not 100% effective at preventing HIV and clients need to be
counselled that they should use other prevention methods as well.
Eligibility Criteria
•
•
•
•
•
No suspicion of acute HIV infection
Test HIV negative at a health facility
Interested in PrEP and willing to be adherent
Able to attend regular 3-month reviews and HIV testing
Able to concomitantly apply other prevention methods such as barriers to
prevent the transmission of other STIs
• Willing to stop taking PrEP when no longer eligible.
And: at substantial risk for HIV infection, defined as engaging in one or more of
the following activities within the last six months:
• Vaginal/anal intercourse without condoms with more than one partner
• Sexually active with a partner who is known to be HIV positive or at
substantial risk of being HIV positive
• Sexually active with an HIV-positive partner who is not on effective
treatment (defined as on cART for > 6 months and virally suppressed)
• History of STI
• History of PEP use
• Sharing injection material or equipment
119
PrEP may also be considered for key populations (as defined by the 2017
NASF) or by persons self-selected as high-risk for HIV acquisition. Such
persons should meet the eligibility criteria above.
Recommendations
• PrEP should be taken for a minimum of 7 days in men, 21 days in women to
achieve maximal protection from HIV acquisition before engaging in highrisk sexual exposure and must be continued as long as risky exposure persists
or one remains negative HIV testing is required before PrEP is offered
• Repeat HIV testing every 3 months is mandatory while a client is on PrEP
• The frequent HIV testing during PrEP use should also ideally become an
opportunity for STI screening and management.
• Those who seroconvert while on PrEP should be immediately switched to a
standard first-line regimen
• PrEP should be provided as part of the combination prevention package
(condom use, HTS, family planning, STI screening, etc.)
Lab Tests before PrEP
•
•
•
•
•
•
HIV test (only HIV-negative partners should be on PrEP)
Creatinine (or urinalysis if creatinine not available)
ALT
RPR/RST
Repeat HIV testing is recommended while PrEP is taken every three months
Hepatitis B (those with positive results should be on lifelong TDF+XTC to
treat HBV)
ARV regimen to be used for oral PrEP
• Tenofovir Disoproxil Fumarate in combination with Emtricitabine
(TDF+FTC) is preferred for PrEP.
• However, if Emtricitabine is not available, Lamivudine in combination with
Tenofovir (TDF+3TC) may be used for PrEP.
Lab Monitoring while on PrEP
• Creatinine at 1 month, 2 months, every 3 months for the first 12 months then
annually thereafter
• ALT every 3 months for the first 12 months then annually thereafter
• Repeat HIV testing is recommended while PrEP is taken at one month and
every 3 months
• Necessary lab tests as per indication
• Pregnancy test (especially if the PrEP regimen is TAF-based).
Adherence Support on PrEP
• Support for adherence should include information that PrEP is highly
effective when used with strict adherence.
120
• PrEP users should be advised that PrEP only becomes effective after 7 days
(21 days in women) and must be continued as long as risky exposure persists
or one remains negative.
• Brief client-centred counselling that links daily medication use with a daily
habit (such as waking up, going to sleep, or a regular meal) may be helpful.
• Special programmes to facilitate adherence among particular groups—such
as young people and women—may be needed.
• Support groups for PrEP users, including social media groups (e.g.
https://www.facebook.com/groups/PrEPFacts), maybe helpful for peer-topeer sharing of experience and challenges.
• People who start PrEP may report side effects in the first few weeks of use.
These side effects include nausea, abdominal cramping, or headache, are
typically mild and self-limited, and do not require discontinuation of
PrEP.People starting PrEP who are advised of this start-up syndrome may be
more adherent.
When to Stop PrEP
• PrEP can be discontinued if a person taking PrEP is no longer at risk and
when this situation is likely to be sustained (i.e., no longer engaging in any
high-risk behaviours as defined above).
• PrEP can be discontinued after 4 weeks of elimination of the risk exposure.
• Significant side effects or if the creatinine clearance decreases to <50mL/min.
• If in a serodiscordant relationship, the HIV positive partner has been on ART
for more than 6 months, is known to be virally suppressed, and there are no
other partners, then the HIV negative partner on PrEP may discontinue
therapy. However, for pregnant or breastfeeding women, PrEP should be
continued.
Note: For Step-by-Step guide to PrEP use, refer to the 2020 Zambia Consolidated
HIV Treatment Guidelines.
PrEP considerations for Pregnant and Breastfeeding Women
Pregnant and breastfeeding women, often remain at substantial and increased risk
of HIV acquisition during pregnancy and breastfeeding.
There is no safety-related rationale for disallowing or discontinuing PrEP use
during pregnancy and breastfeeding for HIV-negative women who are receiving
PrEP and remain at risk of HIV acquisition. The guidelines conclude that in such
situations the benefits of preventing HIV acquisition in the mother, and the
accompanying reduced risk of mother-to-child HIV transmission outweigh any
potential risks of PrEP, including any risks of fetal and infant exposure to TDF
and XTC in PrEP regimens. Active toxicity surveillance for ARV use during
pregnancy and breastfeeding is highly recommended.
Although there is limited experience with the use of PrEP in antenatal and
postnatal care services, it is an important new HIV prevention method.
Indications for PrEP in Pregnant and Breastfeeding Women
121
1. A woman taking PrEP who subsequently becomes pregnant and remains at
substantial risk of HIV infection
2. A pregnant or breastfeeding HIV-negative woman who is or perceives herself
to be at substantial risk of HIV acquisition
3. A pregnant or breastfeeding HIV-negative woman whose partner is HIVpositive
4. An HIV- negative woman who is trying to conceive if her partner is HIVpositive.
In such cases, PrEP combined with screening for acute infection, adherence
counselling, safety monitoring and HIV retesting every three months, in addition
to other existing HIV prevention options, including condoms, should be offered.
PrEP Regimen in Pregnant and Breastfeeding Women
TDF + XTC in combination with other ARVs for HIV treatment.
TAF + FTC can be used in patients with CrCl between 30 and 50mL/min, though
TAF is not currently recommended for use in patients with TB or pregnancy.
Note:
• PrEP should be provided as part of a comprehensive package: PrEP is part of
a package of combination HIV prevention and other services that include HIV
testing services, assisted partner notification, provision of male and female
condoms and lubricants, contraception choices and screening and treatment
of STIs.
• A woman’s risk may vary over time as circumstances change. Women should
be supported to start and to stop PrEP if their HIV risk changes. The risk for
HIV acquisition is not constant.
• PrEP can be used with hormonal contraception. Recommended PrEP
regimens do not appear to alter the effectiveness of hormonal contraception.
• PrEP is not for everyone: It is a choice, and women should be making an
informed decision based on their risk for HIV. All women should be
counselled on the range of HIV prevention modalities that they can choose
from to minimize the risk of HIV acquisition during pregnancy.
• Active surveillance of pregnant and breastfeeding women receiving PrEP is
needed to identify and record adverse pregnancy and infant outcomes. Clients
on PrEP need to be followed up at the clinic for routine monitoring.
3.7.2.
Post-Exposure Prophylaxis of HIV (PEP)
Post-exposure prophylaxis is the use of cART to prevent HIV transmission. Nonoccupational exposure to HIV in children is mostly due to sexual abuse. In adults,
exposure to HIV is mostly associated with occupational injuries. The risk of
acquiring HIV infection after occupational exposure to HIV-infected blood is low
(1:300 after percutaneous exposure to <1:1000 after mucocutaneous exposure).
There is no risk of transmission when the skin is intact. Factors associated with
an increased risk include deep injury, visible blood on the device that caused the
injury, injury with a large-bore needle from artery or vein, and unsuppressed HIV
122
viral load in source patient. Body fluids and materials that pose a risk of HIV
transmission are amniotic fluid, cerebrospinal fluid, human breast milk,
pericardial fluid, peritoneal fluid, pleural fluid, saliva in association with
dentistry, synovial fluid, unfixed human tissues and organs, vaginal secretions,
semen, any other visibly blood-stained fluid, and fluid from burns or skin lesions.
Other blood-borne infections are hepatitis B and hepatitis C viruses. Thus all
HCWs should receive HBV vaccination.
Management of occupational exposure to infectious substances includes the
following steps:
Immediately after exposure:
• Clean the site: wash skin wounds with soap and running water. DO NOT
squeeze, allow the wound to freely bleed. If the exposed area is an eye or
mucous membrane, flush with copious amounts of clean water. DO NOT
USE BLEACH or other caustic agents/disinfectants to clean the skin.
• Contact your In-Charge or Supervisor.
• Consult the clinical officer or medical officer, who does the following:
Determine the need for post-exposure prophylaxis (PEP) based on the risk of
transmission and risks and benefits of taking (or not taking) cART.
PEP Recommendations based on the risk category
Risk category
No risk: intact skin
Medium risk: invasive
injury, no blood visible on
needle
High risk: large volume of
blood/fluid, known HIVinfected patient, large-bore
needle, deep extensive
injury
Penetrative sexual abuse
cART
Not recommended
Preferred:
• TDF or TAF + XTC +
DTG
Duration
28 days
Alternatives:
• TDF or TAF + XTC +
DRV-r;
• TDF or TAF + XTC +
LPV-r;
• TDF or TAF + XTC +
ATV-r;
• AZT + 3TC + LPV-r
(children < 20kg)
• AZT + 3TC + DTG
(children ≥ 20kg)
• TAF + FTC + DTG
(children ≥ 25kg)
*For patients with CrCl <50mL/min, replace TDF with AZT
**DTG is effective against both HIV 1 and 2 and prevents integration of the viral DNA into the host DNA.
It should be avoided in pregnancy and for HIV/TB patients on Rifampicin, the dose of DTG should be
50mg twice daily instead of the regular 50mg once daily. For intolerance toDTG (such, insomnia, anxiety,
depression), use a recommended PI
** For patients who intolerant to ATV-r or if the source is HIV-2 infected and cannot tolerate DTG, LPVr should be used.
Clients on PEP should have an HIV test before starting PEP, and a repeated test at 6
weeks and 3 months, consecutively. While on PEP, the client should be reviewed and
offered appropriate laboratory investigations.
123
3.7.3.
Non-Occupational Post-Exposure Prophylaxis (nPEP)
This is the provision of ARVs to individuals with significant exposure to HIV within
72 hours. This should be given especially to individuals who have been sexually
assaulted where the HIV status of the assailant is unknown or in any other
circumstance where there is significant exposure to HIV contaminated body fluid.
Clients who come for nPEP should be evaluated for substantial risk behaviour for HIV
acquisition. Those with substantial risk or repeated requests for nPEP must be
counselled for PrEP.
The ARV regimen for nPEP are the same as those for PEP due to occupational
exposure as shown above.
Considerations before starting ARV therapy:
•
•
•
•
•
•
•
Effectiveness of regimen.
Potential for ser io us adverse effects and toxicity. Side effects and tolerability.
Potential for interaction s with other drugs.
Potential for treatment options should the initial drug combination fail.
Cost and availability.
Patient readiness and the likelihood of adequate adherence.
Presence of pregnancy or the risk of becoming pregnant.
• Presence of tuberculosis and other illnesses -anaemia, peripheral neuropathy, kidney
disease, hepatitis.
• Ability y of the patient to return for regular and reliable follow-up
Recommended Antiretroviral Regimens
The following are the recommended 1st line and alternative ART regimens by
specific populations:
Recommended ART regimens by specific populations (1st line and alternative
regimens)
124
Population
Pregnant & Breastfeeding
women
Children (0-2 weeks)
Children (2 weeks to < 5
years
old)
Children co-infected with TB
Description
All
Preferred 1st line ART
TDF + XTC + DTG
All
<20 Kg
AZT + 3TC + NVP**
ABC + 3TC + LPV-r
20 – 24.9 Kg
ABC + 3TC + DTG
≥ 25 Kg
≥ 30Kg
<20 kg
TAF + 3TC + DTG
TAF + 3TC + DTG
ABC + 3TC + RAL (Double dose
of RAL) or ABC + 3TC + AZT
ABC + 3TC + DTG
Increase the frequency of
DTG to 50mg twice daily
TDF + 3TC+DTG
Increase the frequency of
DTG to 50mg twice daily
20 – 29.9 kg
≥ 30Kg
Adolescents (10 to <19 years
old) weighing ≥ 30Kg
Adults
All
TDF (or TAFc) + XTCd + DTGe
a. EFV 400
Alternative regimen(s)
TDF + XTC + EFV400 or
ABC + 3TC + DTG*
AZT + 3TC + RAL
AZT + 3TC + LPV-r
AZT + 3TC + RAL
AZT + 3TC + LPV-r
ABC + 3TC + LPV-r
ABC + 3TC + DTG
TDF + 3TC + DTG
AZT + 3TC + EFV (> 3
months)
ABC+3TC+LPV-r
(LPV-r should be super
boosted,
otherwise consult expert
opinion)
ABC + 3TC + EFV
ABC + 3TC + RAL
TDF (or TAFc) + XTCd +
EFV400a or
ABC + 3TC + DTG*
is the lower dose of EFV-400mg/day and is the preferred ARV agent in HIV/TB patients on TB treatment
If NVP exposure, the alternative regimen is a PI-based therapy
c. TAF is Tenofovir alafenamide. Avoid in pregnancy and HIV/TB patients on Rifampicin (currently not
recommended)
d. Can either be 3TC or FTC
FTC is not available as a single drug and is expected to be part of the fixed-dose combination TAF+FTC+DTG
e. DTG (Dolutegravir) to be given to ART naïve adolescents and adults. For HIV/TB patients on Rifampicin and
cannot tolerate EFV400, increase the frequency of DTG to 50mg twice daily instead of the usual 50mg once daily
where a single tablet is available
* ABC+3TC+DTG can be used as an alternative for those with renal insufficiency, or where TAF is not available
and EFV is not tolerated
** Use of NVP is only for prophylaxis in infants and treatment for up to 2 weeks of age in absence of Raltegravir
(RAL)
b.
125
3.7.4.
HIV-2 Treatment
Clinicians should:
• Use the preferred standard First-Line regimen TDF (or TAF) + XTC + DTG
If unable to tolerate DTG, substitute with a Lopinavir-ritonavir when
prescribing ART for HIV-2 mono-infected or HIV-1/ HIV-2 co-infected
individuals.
• Not prescribe NNRTIs (NVP, EFV or RPV) or the PI Atazanavir-ritonavir
as part of an ART regimen against HIV-2 mono-infection.
• Consult with a provider with the ATCs in the management of HIV-2 where
there are doubts before initiating ART in HIV-2-infected patients.
• Educate patients with confirmed HIV-2 infection about the types of drugs
that can be used to treat it.
Although HIV-2 is generally less aggressive, and progression to AIDS is less
frequent, HIV-2 responds less predictably to ART when progression occurs,
and response is more difficult to monitor. The standard methods and
interpretation protocols that are used to monitor ART for HIV-1 infected
patients may not apply for HIV-2-infected patients. Some ART regimens that
are appropriate for HIV-1 infection may not be as effective for HIV-2. The
following factors should be considered:
• The majority of HIV-2 infected patients are long-term non-progressors.
• HIV-2 may confer more rapid resistance to ART agents because of wildtype genetic sequence that results in a significant increase in resistance to
ART agents compared with HIV-1.
• Pathways for the development of drug mutations may differ between HIV1 and HIV-2.
Preferred 1st line and alternative ART regimens for HIV-2
Specific
population
HIV-1/HIV-2
co-infected
Description
Adolescents and
adults
Preferred
1st
line regimen
TDF (or TAFa)
+ XTC + DTGb
Alternative regimen(s)
TDF or TAF + XTC + LPV-rd (or
DRV-r) or
ABC + 3TC + LPV-r or
(DRV-r)
ABC + 3TC +DTGf
ABC + 3TC + LPV-r
Children
HIV-1/HIV-2
co-infected
a. TAF should also be avoided in pregnancy and HIV/TB patients on Rifampicin
b. DTG is active against HIV-1 and 2.
d. LVP-r is the only PI that actively works against HIV-2
e. For the alternative regimen for children, refer for consultation or call the Toll-Free line 7040.
f. ABC + 3TC + DTG could be used as an alternative for those with renal insufficiency or where
TAF is not available and LPV-r is not tolerated.
† Positive Health Dignity and Prevention (PHDP) includes: risk reduction, ART adherence,
correct condom use, family planning, STI screening, and partner HIV testing
126
127
Follow-up clinical and laboratory monitoring for HIV patients on ART
Timeline
Enrollment and ART
initiation
Clinical task
- History
and
examination
- Screen
for
TB,
Cryptococcus
- Adherence counselling
- PHDP† messages
- Initiate ART after
adherence counselling
- If no signs and
symptoms of active TB
disease, initiate IPT
(i.e. after ruling out
TB)
Week 2 post-initiation
- Targeted history &
examination
- Screen
for
TB,
Cryptococcus
- Review
adherence,
side effects, toxicity
- Review
laboratory
tests
- Adherence counselling
- Targeted history &
examination
- Screen
for
TB,
Cryptococcus
- Review
adherence,
side effects, toxicity
- Review
laboratory
tests
- Adherence counselling
- Review
adherence,
side effects, toxicity
- Adherence counselling
- PHDP† messages
- Review
laboratory
tests
- Refill ART with enough
supply to next visit
(max.
3
months
supply).
Week 4 post-initiation
Week 12 post-initiation
6
months
initiation
post-
- Review
adherence,
side effects, toxicity
- Adherence counselling
- PHDP† messages
- Review
laboratory
tests
- Refill ART with enough
supply to next visit
(max. 3 months supply
unless transferred to
appropriate
DSD
models).
128
Laboratory tests
- Serum creatinine
- ALT
- Hb or FBC
- Blood glucose
- CD4 count
- CrAg Tests for those with CD4 cell count
<100 cells/microL or WHO Stage III/IV
- Urine-LAM CrAg Tests for those with CD4
count <100 cells/microL or WHO Stage
III/IV
- HBsAg
- Syphilis test
- Urinalysis for protein and glucose, RBCs
- Cholesterol, and triglycerides (especially if
starting PI)
- Serum creatinine (if on TDF)
- Urinalysis (if on TDF)
- Serum creatinine (if on TDF)
- Urinalysis (if on TDF)
- Serum creatinine (if on TDF)
- Urinalysis (if on TDF)
-
Serum creatinine (if on TDF)
Urinalysis (if on TDF)
Viral load
CD4 cell count
Cholesterol and triglycerides (if on PI)
- Review
adherence,
- Serum creatinine (if on TDF)
- Urinalysis (if on TDF)
side effects, toxicity
- Viral load
- Adherence counselling
- CD4 cell count
- PHDP† messages
- Cholesterol and triglycerides (if on PI)
- Review
laboratory
tests
- Refill ART with enough
supply to next visit
(max. 3 months supply
unless transferred to
appropriate
DSD
models).
Those with CD4 cell count >350 cell/microL at baseline and 6 months of ART with. Suppressed viral
load should NOT have subsequent repeat CD4 cell count monitoring as long as the viral load remain
suppressed
12
months
postinitiation and every
12 months
Clinical and laboratory monitoring for HIV-infected pregnant and breastfeeding women
Timeline
Day 0: Enrollment &
ART initiation
Week 2 post-initiation
Week 4 post-initiation
Subsequent visits to
occur per:
- ANC if pregnant
- HEI schedule if
postnatal
and
breastfeeding
- Adult ART schedule
if postnatal and not
breastfeeding
First postnatal visit
24
months
delivery
after
Clinical tasks
- History
and
examination
- If pregnant, focussed
ANC (FANC)
- Screen
for
TB,
Cryptococcus
- Adherence counselling
- PHDP† messages
- Initiate ART after
adherence counselling
- If no signs and
symptoms of active TB
disease, initiate IPT
(i.e. after ruling out
TB)
- Targeted history &
examination
Laboratory tests
- Serum creatinine
- ALT
- Hb or FBC
- CD4 count
- HBsAg
- Syphilis test
- Viral load testing at first contact if eligible for
those on ART
- Urinalysis
- Cholesterol and triglycerides (especially if on
PI)
- Serum creatinine
- Urinalysis
- Screen
for
TB,
- As needed
Cryptococcus,
and
other OIs
- If pregnant, ANC
- Viral load to be done every 3 months during
- Review
adherence,
pregnancy and breastfeeding period
side effects, toxicity
- Serum creatinine and urinalysis at every ANC
- Adherence counselling
visit
- PHDP messages
- Laboratory testing to occur per ANC while
- Review
laboratory
pregnant except for viral load
tests
- VL within 4 weeks before labour & delivery
- Refill ART with enough
- Cholesterol and triglycerides to be done at 6
supply to next visit
months post- ART initiation during pregnancy
(max.
3
months
- Follow adult ART schedule when postnatal
supply).
except for viral load
CD4 cell count to
determine the need for
continuation
of
Cotrimoxazole
- ART dispensed in MNCH until transferred
- Transfer to ART clinic for the continuum of HIV care and treatment
129
- Earlier transfer or referral may be done for logistical reasons or complicated
cases
† Positive Health Dignity and Prevention (PHDP) includes: risk reduction, ART adherence, correct condom
use, family planning, STI screening, and partner HIV testing
Monitoring Side Effects and Toxicities on ART
Changing an ARV drug should be done only after careful review of adherence.
The indication for changing needs to be addressed. A specific ARV drug may
be changed (substitution) because of:
• Toxicity, such as anaemia, peripheral neuropathy, lipodystrophy, liver or
renal abnormalities
• Intolerance or unresolved and prolonged side effects
• Poor adherence: change indicated only to simplify dosing schedule and to
improve adherence
• Occurrence of active TB (refer to the section on TB-HIV co-infection)
• Failure (clinical, immunologic, or virological)
When HIV patients are switched to alternative regimen the goals are to achieve
HIV viral suppression, avoid adverse events, and optimize adherence. Always
do viral load and ensure that the patient is suppressed before switching across
cases.
Treatment Failure
Clinical
Treatment failure should be considered when clinical symptoms appear whilst
on therapy that is suggestive of deteriorating status.
Immunological
Treatment failure is indicated by a drop of CD4 values to below pre-treatment levels
or 50 % from the peak value on treatment or persistent CD4 levels below 50 cells/
mm3 after 12 months on therapy.
Note:
Patients initiating at very low CD4 may not be able to mount an adequate CD4
recovery; in this case, viral load is indicated.
Virologic
Wherever facilities are available to test for viral load, the following may suggest
failure:
• Plasma HIV viral load >400 copies/ml after 6 months on therapy.
Note:
Blips (single level of 50-1000 c/ml are not considered as failure, repeat viral load as
130
soon as possible.
And patients who appear to be failing on treatment while theviral load is undetectable
should be considered to have undiagnosed opportunistic infections or other
concomitant illness.
It should not be concluded, based on clinical criteria, that an ARV regimen is failing
until there has been a reasonable trial of first-line therapy lasting at least six months,
adherence has been assessed and optimized, intercurrent opportunistic infections
have been treated and resolved, and IRIS has been excluded. Clinica l events that occur
before the first six months of therapy are excluded from this definition of failure
because they often represent immune reconstitution inflammatory syndromes related
to pre-existing conditions.
Factors leading to treatment failure
•
•
•
•
•
•
•
Poor adherence to treatment
Prior exposure to antiretroviral treatment with the development of resistance
Primary viral resistance (infected with resistant HIV strain)
Inadequate drug absorption
Suboptimal dosing (e.g. sharing dose because of side effects)
Inadequate or inconsistent drug therapy
Drug interactions.
Management of Treatment Failure
Patients on ART who have a viral load >1000 copies/mL are failing the
treatment and at risk of progression of the HIV disease. Poor adherence is the
commonest cause of treatment failure. Adherence barriers must be evaluated
and corrected before the therapy is changed.
Patients failing treatment are prone to opportunistic infections and a
comprehensive evaluation of the opportunistic infections, especially
Tuberculosis, must be done before therapy is changed.
When patients are switched to Second-Line ART regimens, the goals are to
achieve HIV viral suppression resulting in reconstitution of the clinical and
immunologic status, avoid adverse events, and optimize adherence. LPV-r is
the primary recommended Second-Line PI.
131
Failing 1st line ART
ABC + 3TC + LPV-r
2nd line ART
AZT + 3TC + RAL
ABC + 3TC + EFV
TDF + XTC + DTG*
TAF + XTC + DTG*
ABC + 3TC + DTG*
TDF + XTC + EFV*
ABC + 3TC + EFV**
AZT + 3TC + LPV-r
AZT + 3TC + LPV-r (or ATV-r)
TDF + XTC + EFV**
Pregnant
&
ABC + 3TC + EFV**
Breastfeeding
Women
* Represents newer regimens
**Represents older regimens
AZT + 3TC + LPV-r (or ATV-r)
Specific populations
Children <5 years
old
Children 5-10 years
old
Adolescents and
Adults
Summary of preferred 2nd line ART regimens
Preferred 2nd line ART regimen
If AZT was used in 1st
TDF + XTC + LPV-r (or ATV-r)
line ART
If TDF or TAF was
AZT + 3TC + LPV-r (or ATV-r)
used in first-line ART
Same regimens as recommended for adults and adolescents if no
Pregnant and breastfeeding
previous NVP exposure without tail coverage.
women
On Rifampicin-based
TDF (or TAF) + XTC+ DTG (50mg twice
HIV & TB co-infection
TB treatment: If AZT
daily)
+3TC + EFV was
If DTG not available:
used in the first-line
Double
dose
LPV-r
(LPV-rART
800mg/200mg twice daily)
On Rifampicin-based
AZT + 3TC + DTG (50mg twice daily)
TB treatment: If TDF
If DTG is not available:
(or ABC) + XTC +
Double
dose
LPV-r
(LPV-rEFV was used in
800mg/200mg
first-line ART
twice daily)
If Rifabutin available use same PI regimens as recommended for
adults and adolescents
AZT + TDF + XTC* + LPV-r (or ATV-r)
HIV & HBV co-infection
* TDF+XTC should always be part of the combination in HBV/HIV
co-infections
TDF + XTC + DTG
AZT + 3TC + LPV-ra
HIV-1/HIV-2 co-infected
ABC + 3TC + DTG
AZT + 3TC + LPV-ra
HIV-2 mono-infected
a DO NOT substitute with Atazanavir in HIV-1/HIV-2 con-infection or HIV-2 mono-infection.
Atazanavir is not active against HIV-2
Specific population
Adults and adolescents
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3.7.5. Elimination of Mother-to-Child HIV Transmission (EMTCT)
Description
Prevention of infant acquisition of HIV infection from their mothers during labour and
delivery or after birth through breast-feeding.
The table below depicts interventions to reduce the risk of MTCT and mitigate against
infection.
Risk factors and mitigating intervention
Risk factor
Prevention/mitigating intervention
High viral load
Antiretroviral therapy in pregnancy
Low CD4 count
As above + PCP prophylaxis
Advanced
Diseases
(AIDS)
ART. PCP and TB prophylaxis OI
treatment
Chorioamnionit
is
Identify & treat STI and malaria
Malaria
Provide malaria prophylaxis
pregnancy, IPT & ITNs
Low Vit. A
Maternal Vit. A supplementation does not
reduceMTCT
Pre-maturity
Comprehensive
antenatal
care,
identify at-risk mothers, provide PCP
prophylaxis
Prolonged
rupture
of
Membranes
Comprehensive ANC, safer delivery
practices
and modified obstetric care
Invasive
delivery
procedures
Discourage scalp vein monitoring,
vacuum extraction, episiotomies
and nasal suction
Cracked nipples
Counselling on optimal breastfeeding
practices & breast care
Breast-feeding
Counselling on infant feeding options:
EBF, early and rapid cessation,
replacement feeding etc
133
during
Refer to Section 5.7.4 for eMTCT Guidelines.
3.7.6.
Non-Mother-to-Child (horizontal) Transmission
Description
HIV horizontal Transmission of HIV to children and adolescents through,
• Sexual transmission i.e. Rape
Defilement,
High-risk survival sex,
Married adolescents, (Mentally, psychologically, physically immature).
• Use of contaminated needles
• Other skin-piercing instruments
• Exposure to infected body fluids and transfusion with contaminated blood
and blood products.
The disease status of the rapist or defiler i.e. viral load, the presence of STIs is
an important factor. Any rapist should be assumed as HIV positive unless proven
otherwise.
Management of the sexually assaulted child
• Admit the child where possible
• Take history to establish circumstances leading to the sexual assault
• Examine the child under anaesthesia if possible or sedation to determine the
extent of theinjury and whether the assault is acute or habitual
Ideally, it should be done by a female health worker.
In the presence of the mother or caregiver
• Collect blood for HIV test, HBV, and syphilis screening and plan to repeat them
at 6 weeks, 3 months and 6 months after the assault.
• Collect specimen of genital secretions to be examined for sperm and seminal
fluid
• Take swabs for bacterial STI.
3.7.7. Post-Exposure Prophylaxis for Sexually Assaulted Child
Initiate post-exposure prophylaxis (PEP) after rape or sodomy as soon as possible
because it is most effective if begun within 24 hours of the assault and is probably
ineffective after 72 hours. Also, consider prophylaxis in other situations, such
as exposure to contaminated medical equipment, blood, or other bodily fluids
and after human bites with disruption to the skin.
134
• Prior to offering PEP
Do a rapid HIV test & start PEP only if negative
If positive offer emotional support and supportive counselling, assess for ART
eligibility and provide comprehensive care.
Empirically treat for bacterial STI and vaccinate against HBV
• Offer emergency contraception to adolescents if they have evidence of sexual
maturation.
• Offer trauma counselling to the child and caregivers
• Alert authority as appropriate
• Refer as appropriate to legal services
• Keep good record keeping in view that sexual assault is a criminal offence.
3.7.8. Management of Patients Previously on ART
Individuals who interrupt ART for any reason are at increased risk of
resistance and treatment failure. Management in ART re-initiation is based
on several factors, and a complete history to establish why the treatment
was stopped is critical. For HIV-infected children, caregivers must be
questioned.
• If treatment failure or toxicity is not suspected as the reason for stopping
ART, and previous good adherence is reported, reinitiate original ART
in consultation with next level.
• If previous adherence is poor and there is treatment failure, these
individuals (and caregivers of children) MUST be enrolled in intensive
adherence counselling sessions until there is agreement among the
patient, provider, and adherence counsellor that the patient is ready to
commence Second-Line ART. Use of treatment supporters for such
patients is strongly recommended.
• If severe toxicity is the reason for stopping ART, refer to the next level
and initiate ART using the appropriate drug substitution and counsel
regarding adherence.
• Viral load testing should be done 6 months after re-initiation of the
original regimen to document HIV viral suppression.
• Do not collect viral load tests for patients who present to care while not
taking ART
3.7.9. Management of Pregnant and Breastfeeding Women
defaulters or Failing Therapy
• Due to the risk of the transmission of HIV to the unborn or
breastfeeding infant, pregnant or breastfeeding women who present to
135
care with unsuppressed viral load or who have defaulted treatment must
be switched to effective therapy (second-line if they previously took a
first-line or third-line if they previously took second-line) immediately
while the EAC is in process. DTG-based regimens are recommended in
this situation.
When to stop ART
Patients may choose to postpone or stop therapy, and providers, on a caseby-case basis, may elect to defer or stop therapy based on clinical and/or
psychosocial factors.
The following are indications for stopping ART:
• Patient’s inability to tolerate all available ARV medications
• Patient’s request to stop after appropriate counselling
• Non-adherence despite repeated counselling: treatment should be
stopped to avoid continued toxicity, continued evolution of drug
resistance, and transmitting drug-resistant HIV
• Unreliable caregiver
• For children, the caregiver is instrumental in ART adherence. Any
factors that affect the capability for the caregiver to give medications
consistently may be an indication to stop ART in an HIV-infected child.
• Serious drug toxicity or interactions
• Intervening illness or surgery that precludes oral intake
• ARV non-availability
How to stop ART
• Stop ALL the drugs when discontinuing therapy
• Discontinue EFV; continue the NRTI components (backbone) for 1-2
additional weeks
• Preventive measures, such as condom use and safer sex practices,
should be strongly emphasized for all patients, especially those
discontinuing treatment.
3.7.10. Treatment Failure with No Further Treatment Options
Continue the failing ART regimen unless there are intolerable toxicities or
drug interactions. Even with treatment failure, the regimen is likely to have
some residual antiviral activity. Stopping therapy in the setting of
virological failure can be associated with rapid falls in CD4 counts and
development of OIs.
When to Consult or Refer to the Next Level of Care
The following criteria are indications to consult or refer to the next level:
136
• Suspected hepatotoxicity not responding to standard management (e.g.
TB/HIV co-infection treatment, ALT/AST >5-fold of the upper limit of
normal)
• Second-Line treatment failure or inability to tolerate Second-Line
therapy
• Complications on PI-based regimen
• Severe or life-threatening adverse reactions
• Inability to tolerate therapy despite the change in regimen
• HIV-HBV co-infection with renal insufficiency
Third-Line ART: Second-Line Treatment Failure
Treatment failure is defined by a persistently detectable viral load >1,000
copies/mL. For adolescents and adults, failure is two consecutive viral load
measurements within a three-month interval, with adherence support
between measurements after at least six months of using triple combination
ARV drugs. For children, viral load may still be detectable at 6-9 months
after initiation and does not necessarily mean treatment failure. Viral blips
or intermittent low-level viremia (20–1,000 copies/mL) can occur during
effective treatment but have not been associated with an increased risk of
treatment failure unless low-level viremia is sustained. A repeat blip should
be assessed further at the ATC. Additionally, clinical and epidemiological
studies show that the risk of HIV transmission and disease progression is
very low when the viral load is lower than 1,000 copies/mL
Provision of third-line ART occurs in very rare circumstances and is beyond
the scope of most ART providers. All patients being considered for thirdline ART should have:
• Confirmed Second-Line ART failure (defined by a persistently
detectable viral load exceeding 1,000 copies/mL [i.e., two consecutive
viral load measurements within a three-month interval with enhanced
adherence support between measurements] after at least six months of
using Second-Line ART)
• Genotype (resistance) testing (Figure 17) to an HIV Specialist at an
Advanced Treatment Centre (ATC) with a complete ART treatment
history (i.e., all previous ARV drugs that the patient has taken with the
duration of use)
• Before starting the third line, establish the reason for treatment failure
(e.g., poor adherence, suboptimal dosing, drug-drug interactions) and
conduct intensive adherence counselling sessions until there is an
agreement between the patient, provider, and adherence counsellor that
the patient is ready to commence third-line ART
• Use of treatment supporters for such patients is STRONGLY
recommended
137
• The most likely ARVs to be successful in patients who have followed
National Guidelines are Dolutegravir or Raltegravir (Integrase
inhibitor) or Darunavir with ritonavir (Protease inhibitor) plus optimal
nucleoside background (e.g. TDF+XTC or AZT+3TC)
Other considerations with major constraints:
•
Etravirine: especially if the genotype is available at time of 1st line
NNRTI failure, although in some patients NNRTI mutations persist
even after non-exposure to NNRTIs in Second-Line
• Maraviroc: needs special tropism test before initiation, which is
currently not available in Zambia.
Before switching therapy in suspected treatment failure, HCWs need to rule
out:
•
Poor adherence: change therapy only after enhanced adherence
counselling has been conducted
• Immune Reconstitution Inflammatory Syndrome (IRIS): treat the
underlying condition and continue ART if tolerated
• Untreated OIs: treat the underlying condition and continue ART if
tolerated
• Pharmacokinetics (e.g. Rifampicin reduces NVP or LPV-r blood
levels): switch to EFV or double the dose of LPV-r or switch
Rifampicin to Rifabutin.
Current infections causing a transient decrease in CD4 count: treat
infection, and if possible, repeat CD4 one month after the resolution of
illness to confirm immunologic failure.
Reason for failure
Action
What to do
Poor
compliance
within 8-16 weeks of
therapy
Review the reasons for
poor compliance and
counsel accordingly.
Continue with the same
combination or simplify
dosing.
Poor compliance > 1
6
weeks of therapy
Consider changing
therapy.
Review the reasons
for poor compliance.
Change two drugs.
Treatment failure
Change therapy.
Use drugs not used in the
previous
regimen
preferably new classes.
138
Adverse drug reaction
Check drug-drug
interactions.
Stop the drugs if
continuation is of no
benefit to the patient.
Change
drug.
Depression
Psychosocial support
Refer to appropriate care
provider
3.7.11.
the
offending
Immune Reconstitution Inflammatory Syndrome (IRIS) and HIV
Immune reconstitution inflammatory syndrome (IRIS) is an exaggerated
inflammatory reaction from a re-invigorated immune system presenting as the
unmasking of previously sub-clinical opportunistic infections OR clinical
deterioration of pre-existing opportunistic infections OR development of the
autoimmune disease.
•
•
Onset: usually within 2-12 weeks after starting ART
Frequency: 10% among all patients on ART, up to 25% when ART initiated
with CD4 < 50 cells/μL
Risk factors:
•
-
Initiating ART close to a diagnosis of an opportunistic infection
Initiating ART when CD4 is less than 50 cells/μL
Rapid initial fall in HIV-1 RNA level in response to ART in patients with low
CD4 counts
Commonly seen with TB, cryptococcal disease, Kaposi’s sarcoma, and
Mycobacterium avium complex infection
Patients initiated on DTG and with low CD4 counts have a higher risk of
having IRIS
Management of IRIS
-
•
•
•
•
•
Have a high index of suspicion with early complications
ART should be continued
If ART continuation is impossible, temporarily interrupt the ART and restart
the same regimen after OI or IRIS is addressed
Diagnose and treat OI or inflammatory condition
Corticosteroid treatment in moderate to severe cases: Prednisolone 0.51.0mg/kg/day for 5-10 days.
139
4. DISEASES
AND
CONDITIONS
AFFECTING
ENDOCRINE SYSTEM
4.1. DIABETES MELLITUS
Description
Diabetes is a metabolic condition characterized by chronic
hyperglycaemia resulting from the disordered metabolism
of fat, protein and carbohydrates.
Classification of Diabetes mellitus
Diabetes can be classified into four general categories:
1. Type 1 diabetes mellitus (due to autoimmune pancreatic beta-cell destruction)
2. Type 2 diabetes mellitus (due to a progressive loss of pancreatic b-cell insulin
secretion frequently on the background of insulin resistance)
3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or
third trimester of pregnancy and resolves after child delivery)
4. Specific types of diabetes due to other causes, such as:
•
Monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset
diabetes of the young [MODY])
•
Diseases of the exocrine pancreas, e.g., cystic fibrosis and pancreatitis.
Drug or chemical induced diabetes, e.g., glucocorticoid use, in the treatment
of HIV/AIDS, or after organ transplantation (post-transplantation diabetes
mellitus).
•
Epidemiology of Diabetes Mellitus
Type 1 and type 2 diabetes mellitus occur in both children and adults. Type 2
diabetes (T2DM) is the most prevalent form of diabetes worldwide, affecting
more than 400 million people around the world.
Diagnosis
The classic symptoms of diabetes are a fasting plasma glucose of >7mmol/L
or random plasma glucose of >11.1 mmol/L is adequate.
The test must be repeated on at least one other occasion. This is a blood
sample from venous blood
Note: Urine glucose can only be used as a preliminary screening tool in the
absence of blood glucose. The patient should be sent to a level where blood
glucose can be done.
If only a glucometer is available, then the fasting capillary glucose level used
is > 6.1mmol/L, but the random capillary glucose remains at > 11.1 mmol/L.
140
Note: Casual or random is defined as any time of the day without regard to
time since last meal. Fasting is defined as no caloric intake for at least 8
hours.
Diabetes mellitus should be investigated using fasting plasma glucose (FPG)
or haemoglobin A1c (HbA1c), which unlike the oral glucose tolerance test
(OGTT) do not require any special patient preparation. Fasting for FPG
testing is defined as not having any meal overnight for at least 8 hours. Repeat
FPG or HbA1c testing is advisable to confirm the diagnosis. An OGTT can
be carried out if FPG and HbA1c are inconclusive.
4.1.1.
Type 1 Diabetes mellitus
Description
This was also previously referred to as Insulin Dependent Diabetes Mellitus
(IDDM). It usually occurs in children and young adults. Occasionally, it can
be found in adults.
Clinical features
The rate of type diabetes progression is dependent on the age at the first
detection of antibody, number of antibodies, antibody specificity, and
antibody titre.
Type 1 diabetes patients often present in an acute state.
Clinical characteristics at diagnosis
Symptoms
• Blurred vision
• Frequent urination (polyuria)
• Increased thirst (polydipsia)
• Increased hunger (polyphagia)
• Weight loss but can be normal/underweight
• Tiredness/weakness
Signs
• Weight loss
• Dehydration
141
Laboratory findings
• Elevated blood glucose
• Ketoacidosis
Treatment
All newly diagnosed patients need to be referred for initiation of treatment
and stabilisation.
Drugs
Soluble insulin on its own or mixed with isophane insulin (0.6 - 1.5 units/kg)
subcutaneously over 24 hours in 2 or 3 divided doses per day. Adjust the dose
to keep the blood sugar levels between 6 - 8 mmol/L.
Dietary control
• Avoid sugar and sugar-containing foods and drinks.
• Take meals regularly.
• Consult nutritionist or dietician on diet modification.
Supportive
Monitor the following:
• Blood pressure
• Renal function
• Blood glucose
• Hydration
• Serum electrolytes and minerals
• Urine sugar
• Urine ketones
Treat infections if any.
Teach the patient and carers about the disease and its management.
Encourage regular exercise
Regular review of the patient at a specialist clinic/hospital
4.1.2.
Type 2 Diabetes Mellitus (T2DM)
Description
This was also previously known as Non-Insulin Dependent Diabetes Mellitus
(NIDDM). It usually occurs in older people and its onset is insidious.
Clinical features
These may be mild and may not cause the patient to seek medical attention.
This condition is often discovered when a complication arises. There is
usually a delay of many months or years from onset to diagnosis.
142
The following are the common features:
Symptoms
• Obesity
• Blurred vision
• Frequent urination/polyuria
• Bedwetting
• Increased thirst/polydipsia
• Weight loss
• Infarct/angina
• Stroke
• Susceptibility to infections e.g. genital tract/urinary tract infections (vulva
itching in women)
• Claudication
• Paraesthesia/pain
• Foot ulcer
Signs
• Dehydration
• Weight loss
Investigation findings
• Elevated blood glucose
• Blood lipid abnormalities
Treatment
Diet and Exercise
Diet and exercise are the mainstays in the treatment of T2DM. This should
be tried first in all patients except those with very high glucose levels and
those who are severely symptomatic. Those who fail to respond to diet and
exercise can then move on to taking drugs.
Medication therapy
The two main classes of drugs used in Zambia are sulphonylureas and
biguanides.
Sulphonylureas
• Glibenclamide: Initially can be given orally once a day or in two divided
doses. The usual dose is 5mg orally daily taken before breakfast up to a
maximum of 20mg in divided doses before food, depending on the
143
patient’s response. Doses above 20mg will not result in any improvement
in glucose control.
• Glipizide; adults initially 2.5 – 5mg daily adjusted according to response,
dose to be taken shortly after breakfast or lunch. Doses up to 15mg may
be given as a single dose, higher doses to be given in divided doses,
maximum 20mg per day.
• Sulphonylureas can be given together with biguanides.
Biguanides
Metformin is the preferred drug in obese patients in addition to dietary control
and exercise. It may also be added in patients who have reached the
maximum dose of a sulphonylurea without achieving adequate control of
blood sugar levels.
• Metformin 500mg orally 2-3 times daily or 850mg orally 2-3 daily with
or after food. The maximum dose is 2.55g daily in divided doses.
NOTE:
Dosage increments in oral antidiabetic drugs should be gradual i.e. at 1 to 2week intervals.
Insulin
Insulin may be used alone or added on if the combination of sulphonylurea
and biguanide fails to achieve adequate control of blood sugar.
Insulin is available in two types of preparations:
i) Short duration, soluble forms, for rapid onset of action
ii)
Intermediate duration
Most patients are best started on intermediate action insulin twice daily and a
short-acting form may be added to control any hyperglycaemia which may
follow breakfast, lunch or supper.
It is important to note that variability in absorption within the same individual
and between two individuals can happen.
Insulin doses should be calculated and determined on an individual patient
basis, gradually increasing the dosage until the patient stabilises. Care should
be taken not to cause hypoglycaemia.
If diabetes control is poor on diet, exercise and oral drugs, do not delay
starting insulin.
144
Withdrawal of oral (sulphonylureas & biguanides) drugs should be
commenced only after the insulin therapy has been initiated. In some patients,
metformin and insulin combination can be given.
Supportive
• Monitor blood glucose levels regularly
• Prescribe appropriate diet
• Careful weight reduction in obese patients
• Encourage regular exercise
• Regular review of the patient at a specialist clinic/hospital
• Educate patient and carers
Patient and carers education
Patients and carers should be educated on the following:
• Identification of symptoms of hypoglycaemia
• Principles of foot care
• Injection techniques and how to look after syringes and insulin
• Types of insulin preparations available
• Monitoring blood glucose or urine glucose
• Diet control i.e. meal intervals depending on the type of insulin.
Note:
Weight reduction for obese patients and appropriate diet is key in the process
of managing diabetes mellitus.
Dietary control and exercise should be continued alongside drug therapy.
4.1.3.
Hyperglycaemic/Ketoacidosis Coma/Precoma
Description
Severe uncontrolled diabetes with very high blood sugar requiring emergency
treatment with insulin and intravenous fluids and with a blood ketone body
concentration of greater than 5mol/L, the common precipitating causes are
infection, management errors and new cases of diabetes, but there is no
obvious cause in about 40% of episodes.
In Africa, DKA carries high mortality – through delayed diagnosis,
inadequate treatment and late presentation. It presents at any age although
there is a well-defined peak at puberty.
Clinical features of diabetic ketoacidosis
145
•
•
•
•
•
•
•
•
•
•
•
•
•
Polyuria, nocturia, thirst
Weight loss
Weakness
Visual disturbance
Abdominal pain
Leg cramps
Confusion, drowsiness, coma
Dehydration
Hypotension
Tachycardia
Rapid and deep respiration (Kussmaul breathing)
“Acetone” odour
hypothermia
Management
Children
Establish and maintain cardiovascular and renal functions.
Correct fluid and electrolyte deficiencies and imbalances. Give insulin to
reduce blood sugar.
Determine the precipitating causes of the crises.
Look out for and prevent any complications.
Fluid and electrolyte replacement:
i.- Sodium chloride 0.9%, rapid infusion 20ml/kg in the first one hour then
assess urine output. When blood sugar falls to between 10 – 16 mmol/L,
change to dextrose 5% to prevent hypoglycaemia. ii.- If the potassium level
is low or normal, add potassium intravenously 20 – 40 mmol/L of intravenous
fluid. This should be given after insulin therapy has been commenced.
Insulin
Soluble insulin 0.1 units/kg/hour, given intravenously, as a continuous
infusion. When blood sugar levels reach 10 mmol/L reduce to 0.05
units/kg/hour.
Once the patient has stabilised, manage as for Type 1 diabetes mellitus
Adults
Conduct assessments and investigations as in children Fluid and electrolyte
replacement:
i.- Isotonic (normal) saline (sodium Chloride 0.9%) rapid infusion 1 – 2L
in the first one hour then reassess
146
and repeat as needed. Normally 6-8 litres in the first 24 hours. When blood
sugar falls to between below 14 mmol/L change to dextrose 5% to prevent
hypoglycaemia. If sodium level more than 150 mmol/L give half strength
(hypotonic) saline.
ii.‚ Sodium bicarbonate (600ml of 1.4%, or 100ml of 8.4% in a large
cannulated vein) if pH>7.0
iii.‚Potassium ‚
1.‚Add dosage below to each 1L of infused fluid: ‚‚
(a) If plasma K<3.5mmol/L, add 40 mmol KCI ‚‚
(b) If plasma K 3.5-5, 5mmol/L, add 20mmol KCI
Insulin
i. Soluble insulin 5-10 units (0.1 units/kg/hour intravenously), as a
continuous infusion NOTE: Soluble Insulin given as an intravenous bolus
is rapidly destroyed within a few minutes. Intravenous insulin must
always be given as a continuous infusion. When blood sugar levels reach
10 -14 mmol/L reduce to 2-4U/h (0.05 units/kg/hour) or titrate against
blood glucose levels and when a patient is able to take oral feeds give
soluble insulin 2-3 times before meals
OR
ii. Initially soluble insulin 20 units intramuscularly stat then 5-10 units
intramuscularly hourly until blood sugar is 14mmol/L. When blood
glucose is 10 – 14mmol/L give 8 units 4 hourly subcutaneously until the
patient is able to take oral feeds. When the patient is taking food orally,
change to soluble subcutaneously twice or three times before meals.
4.1.4.
Hypoglycaemia in Diabetes Mellitus
Description
This is a condition in which the blood sugar falls to lower than 3 mmol/L with
the attendant signs and symptoms of the disorder. The classical clinical
features may, occur at higher levels than this in some patients, especially
those with poorly controlled type 2 diabetes. The causative factors include
inadequate or delayed food consumption, alcohol consumption, excess
insulin dosage or wrong injection technique, exercise, inattention or
combination of these factors.
147
Clinical features
Symptoms
• Weakness
• Fatigue
• Sweating
• Hunger
• Abdominal pain
• Headache
• Nausea
Signs
• Pallor
• Tremor
• Tachycardia
• Irritability
• Speech difficulty
• Incoordination
• Loss of concentration
• Drowsiness
• Abnormal behaviour
• Disorientation
• Convulsions
• Coma
Treatment
In all diabetics in a coma, with no means of ascertaining the blood glucose
level, give oral or intravenous glucose. If the patient is conscious and able to
take orally give a sugar-containing drink or food. If the patient is unable to
take orally give:
i. 20 ml of 50% glucose as an intravenous bolus (OR
50 ml of 20% glucose)
ii. Follow up if necessary with intravenous infusion of 10% or 20% glucose,
100ml/hour. OR
iii. Administer 0.5 mg to 1.0 mg glucagon intramuscularly or intravenously.
IM or IV Glucagon must be followed by oral glucose
iv. A continuous infusion of 10% or 20% glucose (dextrose) may be required
for 24 to 72 hours if overdosage of long-acting insulin or sulphonylureas
(chlorpropamide or glibenclamide) is the cause of the hypoglycaemia
Monitor blood glucose regularly and maintain between 6 and 8 mmol/L.
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4.1.5.
Diabetes Mellitus in Pregnancy
Gestational Diabetes Mellitus (GDM)
Description
GDM is diabetes that is first diagnosed in the second or third trimester of
pregnancy that is not pre-existing type 1 or type 2 diabetes and resolves after
child delivery.
Women diagnosed with diabetes in the first trimester of pregnancy should be
classified as having Type 2 diabetes or, Type 1 diabetes or monogenic
diabetes.
GDM is a risk factor for the development of type 2 diabetes after delivery.
Therefore, women with a history of GDM should receive lifelong screening
for prediabetes and type 2 diabetes.
Diabetes mellitus in pregnancy is usually seen in women who are already
diabetic before pregnancy or have had a history of diabetes in the family.
However, when this condition occurs in non-diabetics it usually presents in
the second trimester.
All pregnant diabetic patients should be referred for specialist treatment.
Known diabetic patients should be counselled before conception and diabetes
should be well controlled both before conception and throughout the
pregnancy. (See also chapter 5.7.1).
149
5.
OBSTETRIC
AND
GYNAECOLOGICAL
CONDITIONS
5.1.
ANTENATAL CARE
The goal of antenatal care is to promote maternal and newborn health and
survival through:
• Early detection and treatment of problems/complications in the mother
and foetus e.g. proteinuria, hypertension, syphilis, foetal abnormality,
mal-presentation, intrauterine growth retardation, etc.
Prevention of complications and diseases such as malaria, anaemia and
neonatal tetanus.
• Birth preparedness and complication readiness. Provide a Birth Plan
which indicates the place of delivery and transport to the delivery site
among other key decisions.
• Health promotion e.g., health education, counselling and provide
supplementation of iron, folic acid, iodine, calcium and vitamins,
provision of ITNs.
A minimum of 8 antenatal contacts are recommended, with the first contact
scheduled to take place in the first trimester (up to 12 weeks’ gestation), Two
contacts scheduled in the second trimester (at 20 and 26 weeks’ gestation)
and 5 contacts in the third trimester (at 30, 34, 36, 38 and 40 weeks’ gestation.
The client should return for delivery if not delivered at 41 weeks.
During the first visit, the following should be done:
• General, obstetric and gynaecological history
• Full physical examination
• Basic investigations i.e. confirmation of pregnancy, Hb, Group and
Rhesus, HIV, RPR, Hepatitis, urinalysis and ultrasound where available
• Supplements i.e. haematinics (iron 30 – 60 mg elemental Iron daily, Folic
acid 400mcg or 0.4mg daily, Mebendazole 500mg stat)
• Malaria (IPT-SP up to 6 doses can be given at least one month apart
between doses – 3tabs of 500mg/25mg SP). Patients on Co-trimoxazole
should not receive SP.
• Tetanus prophylaxis should be given
• Provider Initiated Counselling and Testing (PICT)
During the second and subsequent visits, the following should be done:
• Examine for growth of the foetus
• Maternal well being
• Check on medications given previously
150
•
•
•
•
•
•
•
5.2.
Check presentation of the foetus
Discuss the place of delivery and mode of delivery
Discuss warning signs/danger signs
Malaria prophylaxis (IPT-SP)
Iron and folic acid supplementation
ART/PrEP
Viral load at 36 weeks (a month before delivery)
NORMAL LABOUR
Monitoring of labour
 Maintain infection prevention practices
 Use a partogram on all patients
 Check for foetal and maternal well-being and progress of labour
 Provide active management of the third stage of labour.
 After the baby has been delivered onto the mother’s abdomen, palpate the
abdomen to rule out the presence of an additional baby(s) and then give
oxytocin 10 units intramuscularly within 1 minute of delivery
Oxytocin is preferred and effective 2 to 3 minutes after injection, has minimal
side effects and can be used in all women. If oxytocin is not available, give
Ergometrine 0.2mg intramuscularly or Misoprostol 600mg sublingual. Make
sure there is no additional baby(s) in the uterus before giving these
medications.
Clamp the cord close to the perineum using sponge forceps (Spencer Wells)
and deliver placenta using controlled cord traction. Allow sufficient flow of
blood to the baby before clamping. Hold the clamped cord and the end of the
forceps with one hand. Place the other hand just above the women's pubic
bone and stabilize the uterus by gently pushing the uterus up. This helps
prevent inversion of the uterus
Keep slight tension on the cord and await a strong uterine contraction or rub
up a contraction. If necessary, use sponge forceps (Spencer Wells) to clamp
the cord closer to the perineum as it lengthens. Do not wait for a gush of blood
before applying traction on the cord.
Keep slight tension on the cord and await a strong uterine contraction or rub
a contraction. If necessary, use sponge forceps (Spencer wells) to clamp the
cord closer to the perineum as it lengthens. Do not wait for a gush of blood
before applying traction on the cord
151
When the uterus becomes rounded or the cord lengthens, very gently pull
downwards on the cord to deliver the placenta. Continue to stabilise the uterus
with the other hand.
If the placenta does not descend during 20-30 seconds of controlled cord
traction (i.e. there are no signs of placental separation), do not continue to pull
on the cord:
–Gently hold the cord and wait until the uterus is well contracted again. If
necessary, use sponge forceps to clamp the cord closer to the perineum as it
lengthens.
–With the next contraction, repeat controlled cord traction with counter
traction.
Analgesia in labour
• Pethidine 100mg IM stat
• Naloxone 10 micrograms/kg may be given to a neonate to reverse
Pethidine induced respiratory depression
General care
• Encourage women to be with a support person at all times.
• Encourage ambulation and frequent oral fluid intake
• At delivery woman must choose which position to take
Immediately following birth
•
•
•
•
•
•
Gently perform a uterine massage
Provide oxytocics/ergometrine
Estimate blood loss
Examine for and repair lacerations
Examine placenta and membrane for completeness
Provide close surveillance of vaginal bleeding, uterine hardness and vital
signs during the first 6 hours postpartum:
– Every 15 minutes for the first two hours; then
– Every 30 minutes for the next one hour; then
– Every hour for the next three hours.
• Initiate breastfeeding within an hour of delivery;
– Promote early and exclusive breastfeeding
– In the event of the mother being HIV positive, ensure the mother is on
ART and the baby receives ART for the duration of breastfeeding
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5.3.
ANTEPARTUM HAEMORRHAGE (APH)
Description
Antepartum haemorrhage (APH) is defined as per vaginal bleeding after 22
weeks of gestation to delivery of the baby.
The main causes of APH are
• Placenta previa
• Abruptio placentae
• Cervical lesions e.g. cancer, ectopy, polyp
• Vasa Previa
Clinical features
• Painful or painless PV bleeding (provoked or unprovoked)
• The uterus may be woody hard with no relaxation
• High pulse rate
• Low blood pressure
• Air hunger with severe bleeding
• Other signs of shock e.g. cold clammy hands
Investigations must distinguish between placenta previa and abruptio
placentae. No vaginal examination is to be performed. Speculum examination
should only be performed after placenta previa has been ruled out. Refer to a
hospital
Emergency care
• I.V access
• Normal saline infusion
• Transfer to hospital for confirmation of diagnosis by clinician or
examination by ultrasound scan, where available, for clinical examination
• Rh-negative patient may need anti-D
Note that antepartum haemorrhage is a serious complication
5.3.1.
Placenta previa
Description
This is a condition in which the placenta is implanted in the lower segment of
the uterus.
Clinical features
• Painless PV bleeding
• ± malpresentation, high presenting part
153
• Present foetal heart
• Recurrent vaginal bleeds
• Relaxed uterus
Specific management
If the baby is premature and bleeding has stopped, conservative management
is recommended until 36 - 38 weeks:
•
•
•
•
•
Keep woman in the hospital until delivery
Crossmatch 2 units of blood at all times
Keep haemoglobin at more than 9g using haematinics or blood
transfusion
Give
Dexamethasone
6mg
12
hourly
4
doses
intravenously/intramuscularly.
If there is heavy bleeding proceed to caesarean section
Plan delivery if foetus is mature, dead, or has major anomalies
5.3.2.
Abruptio placentae
Description
This is a condition in which there is premature separation of a normally
implanted placenta before delivery of the baby. The patient must be referred
to a hospital.
Clinical features
• May have been provoked by Artificial Rupture of Membrane (ARM),
External Encephalic Version (ECV), hypertensive disorder
• Painful Per Vaginal (PV) bleeding
• Foetus may be dead, difficult to feel foetal parts
• Height of fundus may be higher than dates
• Tender tense abdomen
• Signs of shock
• Retro placental bleeding may be concealed
Specific management
• Nurse in high dependency ward
• Rapid infusion of normal saline or ringers lactate
• Crossmatch 4 units of blood and commence transfusion as soon as
possible
• Catheterise patient
• Give morphine 15mg intramuscularly stat
154
•
•
•
•
Do bedside clotting time
Perform artificial rupture of membranes to induce labour
Active management of the third stage
After delivery give oxytocin 10 units in normal saline running at 20 drops
per minute for 2 – 4 hours
Be aware of postpartum haemorrhage due to atonic uterus or coagulopathy.
5.3.3.
Cervical lesion
Cervical lesions can cause bleeding in pregnancy and should be checked.
Remember that a speculum should only be passed after a scan has been done
to locate the placenta to avoid precipitating bleeding in a placenta praevia.
The following should be checked:
• Cancer of the cervix
• Cervical ectopy
• Cervical polyps
5.3.4.
Vasa Previa
Description
A condition in which the foetal blood vessels are unsupported by either the
umbilical cord or placental tissue, traverse the foetal membranes of the lower
segment of the uterus below the presenting part. Vasa Previa occurs when
foetal blood vessel(s) from the placenta or umbilical cord cross the entrance
to the birth canal, beneath the baby. It can result in rapid foetal haemorrhage
or lack of oxygen.
Symptoms
• Present with sudden onset of abnormally heavy or small amounts at
rupture of membranes.
• Foetal bradycardia, then death.
Warning Signs
Very difficult to diagnose antenatally before rupture of
membranes
• Low-lying placenta
• Painless birthing bleeding.
Investigations
• Ultrasound
• Check the placental cord connection for velamentous cord insertion.
155
• Sonography
• Colour Doppler
Supportive Treatment
• Use of tocolytics to stop all uterine activity
• Bedrest
• No sexual intercourse
• No vaginal examinations
• No lifting of heavy items
• No heavy straining during bowel movements (use of stool softeners)
Hospitalization; (if suspected antenatally)
• Foetal monitoring
• Regular ultrasounds to monitor the progression of vasa previa
• Steroid treatment to develop fetal lung maturity
• Elective delivery, most important
• Initiate breastfeeding within an hour of birth
When not diagnosed antepartum, aggressive resuscitation complete with
blood transfusion for the infant if necessary must be planned for and/or
expected.
5.4.
POSTPARTUM HAEMORRHAGE (PPH)
Description
This is per vaginal (PV) bleeding of 500ml or more or any amount resulting
in cardiovascular collapse or hypovolaemic after delivery of the baby. It is
called primary PPH when it occurs within the first 24 hours and secondary
PPH thereafter up to 6 weeks.
This is caused by:
• Atonic uterus
• Genital tract trauma, e.g., ruptured uterus, cervical vaginal tears and
vulval haematoma
• Secondary coagulopathy
• Uterine sepsis
Clinical features
• Excessive vaginal bleeding
• May be in shock
• High pulse rate equal to or more than 100/min
156
• Low BP less or equal to 80/40mm
• Air hunger (restlessness)
• Cold sweat
Emergency care
To provide a timely surgical plan such as uterine tamponade, B Lynch suture,
hysterectomy, internal iliac artery ligation.
This must be teamwork
• Call for help
• Rub up the uterus for a contraction and to expel clots
• Obtain IV access with 2 large-bore cannulas (16G or 14G). Start IV fluids
(NS/Ringers Lactate: the first litre to run in fast in 15minutes.
• Repeat oxytocin 10 units intramuscularly
• Give oxytocin 20 units in 1Litre normal saline running at 20 drops per
minute or oxytocin 40IU IV in 500ml of NS at 125ml/hr. Where
ergometrine or syntometrine is available give 0.5mg IM/IV stat or
intramural.
• If bleeding persists, and to be given only within 3 hours of PPH
tranexamic acid 1g in 10ml (100mg/ml) IV at 1ml/min over 10minutes.
The dose can be repeated after 30 minutes if bleeding persists.
• Misoprostol 1000mcg (5 x 200microgram tabs) PR can be given
alternatively or in addition to;
• Bimanual compression of the uterus to be done concurrently.
• If bleeding persists, then intrauterine tamponade using inflated Foley
catheter or condom (500mls of N/saline)
• Give blood and fluid replacement as required
• Monitor urine output/catheterise the bladder
• If PV bleeding persists yet uterus is well contracted, check genital tract
for trauma and for coagulopathy
• Where available, central venous pressure (in the absence of
coagulopathy) monitoring is valuable
• In uncontrollable PPH timely surgical intervention is important, then OT
for B Lynch/Hayman brace suture, uterine artery ligation or hysterectomy
to be done.
Nurse in high dependency ward - Special Observation Unit (SOU) of the
hospital.
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5.5. UNCONSCIOUS OBSTETRIC PATIENT
A pregnant woman may be brought into a health facility unconscious without
much history. Management therefore will mainly depend on clinical
examination and investigations. The obstetrician should work in collaboration
with the physician.
Differential diagnosis
• Eclampsia
• Cerebral Malaria
• Meningitis
• Hypovolaemic shock
• Organophosphate poisoning
• Diabetic coma
Management
Call for Help
The following should be done as the Airway, Breathing and Circulation
(ABC) of resuscitation:
• Take a quick history from carer and note the patient’s previous notes
• A quick examination should include; blood pressure (BP), pulse,
temperature, jaundice, cyanosis, hydration, sweating, cold clammy
extremities, respiration, heart sounds, PV bleeding, fundal height, foetal
viability and neck stiffness.
Investigation
Cerebral spinal fluid for bacteriology and biochemistry, blood for
haemoglobin level, malaria slide, blood sugar and urea urinalysis
Treatment
• Keep airway patent and give oxygen (patient may need ventilation)
• Secure intravenous line access, start with 50mls of 50% dextrose unless
sugar levels are normal
• Atropine 0.6 – 2.4mg IV /15min until normal pulse/dilatation of pupils
for organophosphate poisoning
• Treat cause
• Catheterize
• Nurse in a left lateral position
• Keep patient in a high dependency ward (Special Observation Unit)
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5.6.
PRE-ECLAMPSIA AND ECLAMPSIA
Description
Pre-eclampsia is pregnancy-induced hypertension with proteinuria occurring
after 20 weeks of gestation. There are 2 types; mild pre-eclampsia and severe
pre-eclampsia. When convulsions appear in this syndrome it is then called
eclampsia. This is an obstetric emergency requiring immediate referral to a
hospital
Diagnosis
5.6.1.
Mild pre-eclampsia
This is when two measurements of diastolic blood pressure taken 4 hours
apart read 90-100mmHg with proteinuria up to 2+ and above.
5.6.2.
Severe pre-eclampsia
This is when diastolic blood pressure is 110mmHg or more with increasing
proteinuria of 3+ or more.
5.6.3.
Eclampsia
This is when there is a diastolic blood pressure of 90mmHg or more with
proteinuria of 2+ or more and convulsions.
The signs of impending eclampsia are:
• Epigastric tenderness
• Increased tendon reflexes
• Blurred vision
5.6.4.
Pre-eclampsia management in outpatients
The reduction of blood pressure does not abort the progression of the disease
process and its effect on the foetus. At present, the only effective management
of preeclampsia is delivery of the baby. The more severe the disease
condition, the greater the risk to both the mother and the baby. If the risk to
the mother's health is significant the baby should be delivered even if it is
nonviable. If the disease is mild or moderate the baby can be kept in utero
until it is viable provided close observation is kept on the mother, looking out
for the complications of pre-eclampsia.
159
All patients with pre-eclampsia should have a mid-stream urine (MSU)
specimen taken and be seen by a specialist. A check should be kept on the
baby's growth with serial measurement of symphysio-fundal height. The
woman should keep a kick chart. No anti-hypertensive medications are
usually required for mild pre-eclampsia.
5.6.5.
Mild pre-eclampsia and gestation less than 37 weeks
Management should include:
• Monitoring blood pressure
• Monitoring of foetal well-being (kick chart, serial scans)
• Monitoring of urine output and urinalysis for proteinuria
• Renal function test
• Normal diet
Do not give anti-hypertensives, sedatives, tranquillisers or anticonvulsants.
5.6.6.
Severe pre-eclampsia and eclampsia
Once the blood pressure is above 160/110mmHg the mother is at risk of
stroke. Other complications include:
 Renal failure
 Cardiac failure
 Foetal death
 Eclampsia
 HELLP Syndrome
The definitive treatment is delivery. The baby should be delivered.
There are four principles involved in management:
• Prevention and control of convulsions
• Control of hypertension
• Maintenance of fluid balance
• Prevention of Respiratory Distress Syndrome (RDS) and Delivery of the
baby
General Management
• For patients with eclampsia maintain an airway.
• Strict monitoring of urine output (should not be less than
30ml/hour)
• Urinalysis for proteinuria
• Renal function test
• Maintain strict fluid balance chart
160
• Do bedside clotting test (failure of a clot to form after 7 minutes or a soft
clot that breaks down easily suggests coagulopathy)
• Nurse in a left lateral position
Prevention of convulsions
In severe preeclampsia it is important to prevent convulsions as the risk is
very high:
• Magnesium sulphate 4g (20mls of 20%) IV over 20min followed by 5g
(10mls of 50%) IM in each buttock. Add 1ml of 2% lignocaine to IM
injection. Give MgS04 every 4hours up to 6 doses, to be given once
decision to deliver has been made.
Management of convulsions
The drug of choice is magnesium sulphate injection. Diazepam, despite its
effects on the baby, may be used when magnesium sulphate is not available.
Diazepam injection must be given intravenously, never orally or
intramuscularly.
- Call for help
- Check airway, breathing and circulation (ABC)
- Protect patient from injury (place on left lateral position, place in bed with
side rails or on the floor)
- Nurse in high dependency ward or ICU
- Control BP (goal SBP<160, DBP < 110): give Hydralazine IV or
Nifedipine PO or Labetalol
- Prevent more seizures: give MgSO4 4g (20mls of 20%) IV slowly over
20 minutes Loading Dose.
- Follow promptly with MgS04 5g (10mls of 50%) in each buttock deep
IM add 1ml of 2% lignocaine in the same syringe. If convulsions re-occur,
give 2g, 20% MgS04 IV over 5 minutes.
- Maintenance dose: give 5g (10mls of 50%) MgS0 4 IM with 1 ml of 2 %
lignocaine every 4 hours in alternate buttocks until 24 hours after birth or
after last convulsion (whichever is later)
- Once fits are controlled assess for the mode of delivery (assisted vaginal
delivery or caesarean delivery).
Before repeating MgSO4 administration, ensure that:
• Respiratory rate is at least 16 per minute
• Patellar reflexes are present
• Urine output is at least 30ml per hour over 4 hrs.
Withhold or delay MgSO4 if:
• Respiration rate falls below 16 per minute
161
• Patellar reflexes are absent
• Urinary output falls below 30ml per hour over preceding 4 hrs.
• Keep antidote ready
In case of respiratory arrest
• Assist ventilation (mask and bag apparatus, intubation)
• Give an antidote, calcium gluconate 1g (10ml of 10% solution)
intravenously slowly over 10 minutes until respiration begins.
• As an alternative to magnesium sulphate, give diazepam bolus 5-10mg
IV over 2 minutes if the patient is convulsing.
Management of hypertension in pregnancy
The drug of choice is Hydralazine. The drug should be titrated against the
blood pressure to achieve a diastolic pressure of 90 – 100mmHg.
• If diastolic BP 110mmHg reduce by giving Hydralazine IV 5mg bolus
and repeated every 20 to 30 minutes or give nifedipine 10mg sublingually
• Labetalol 20-40 mg i.v every 10-15 minutes (Maximum dose 220mg.
Avoid Labetalol in asthma and congestive cardiac failure)
• Give Methyldopa 250 mg -500mg every 6-8 hours orally for maintenance,
or
• Labetalol 100mg oral b.i.d (maximum dose 2400mg/day).
Fluid Balance
Fluid input and output must be monitored. Fluid should be replaced as
required. However, be aware of fluid overload. Do not give more than 2.5
litres in 24 hours.
No matter how oedematous a woman is if the urine production goes below
30ml/hour, the patient should be given a fluid challenge of 1 litre 0.9%
Normal Saline given over 30 minutes. If the response is an increase in urine
more fluid should be given. If there is no response the patient may be
developing renal failure and should be referred to a specialist physician.
5.6.7.
Pre-eclampsia and eclampsia in labour
• The patient should be monitored as a high-risk one with BP checked every
30 minutes or less if necessary listen for the foetal heart every 15 minutes
and/or during and immediately after a contraction
• The patient must be catheterised and fluid input and output monitored
• The patient should be given adequate pain relief
• The second stage of labour should be kept short and an elective vacuum
extraction or forceps delivery done as soon as the patient is fully dilated
• Fresh meconium in the liquor and heart rate abnormality signifies foetal
distress and the baby should be delivered by caesarean section.
162
• Ergometrine should be avoided; instead, Oxytocin 5 units intramuscularly
should be given with delivery of the anterior shoulder.
5.6.8.
Care for the neonate
The baby is likely to be in a poor condition and may require resuscitation such
as;
• Keep warm
• Give Oxygen Ambu bag as required
• Suction
Post-partum care
The patient must be closely monitored for at least 48 hours in a place where
maximum care can be given. This usually means in the labour ward or a
special observation unit (SOU) which is a high dependency unit.
5.7. MEDICAL DISEASES IN PREGNANCY
5.7.1.
Diabetic Mellitus
Pregnancy may turn otherwise well-controlled diabetes into poorly controlled
diabetes. Some women may develop diabetes during pregnancy. These cases
must be referred to the hospital if attended at a health centre.
Diagnosis
Gestational diabetes mellitus
• Fasting plasma glucose 5.1 - 6.9 mmol/L
• 1-hour plasma glucose >10.0mmol/L following a 75g oral glucose load
• 2-hour plasma glucose 8.5 - 11.0mml/L
Diabetes Mellitus
• Fasting plasma glucose > 7mmol/L
• 2-hour plasma glucose ≥ 11.1mmol/L following a 75g oral glucose load
The following principles of care should apply:
• Pre-pregnancy counselling emphasizing the reduced risk of abnormalities
and outcomes with the well-controlled disease at preconception
• Pregnancy counselling emphasizing better outcomes with well-controlled
disease
• May need to change from an oral hypoglycaemic agent to insulin for
better control
163
• Monitoring blood sugar with necessary adjustments to medication (there
is increased tolerance to treatment with each trimester)
• Monitoring foetal growth and looking out for macrosomia with serial
ultrasound scans
• In labour, monitor blood sugar and titrate medication to ensure normal
levels are maintained
• Monitor labour with partograph
• Beware of shoulder dystocia in macrosomic baby
• Watch for hypoglycaemia in the baby (especially if maternal glucose
levels not well controlled)
• Care for the newborn: keep warm, watch for electrolyte imbalance, also
at risk of respiratory distress syndrome
Follow up mothers
Post-Natal Care
• The patient may resort to pre-pregnancy doses of insulin or
hypoglycaemics
• Gestational diabetics may need a glucose tolerance test at 6 weeks as there
is a risk of developing diabetes in some.
5.7.2.
Cardiac diseases
The most common cardiac disease encountered in pregnancy is Rheumatic
Heart Disease (RHD). The most prevalent of RHD is Mitral Stenosis (MS)
and Mitral Incompetence (MI). (See Chapter 7).
Management
• Pre-pregnancy counselling and patient should be referred for an obstetric
opinion before conception occurs
• Give Digoxin 0.25mg daily where there are arrhythmias as in atrial
fibrillation.
• Frusemide should only be used in case of pulmonary oedema
• Admit to hospital in the 3rd trimester in case of pulmonary oedema.
In labour
Keep in high dependency ward in propped up position:
• The patient should be monitored as a high-risk one with Bp checked every
30 minutes or less, if necessary
• Listen for the foetal heart every 15 minutes and/or during and
immediately after a contraction
• The patient must be catheterised and fluid input and output monitored
• The patient should be given adequate pain relief
164
• The second stage of labour should be kept short and an elective vacuum
extraction or forceps delivery done as soon as the patient is fully dilated
Give:
• Pethidine 100mg IM or Fentanyl 50 – 100ug (Fentanyl may be repeated
every hour as needed)
• Cefotaxime 1g 12 hourly (2 doses)
• Oxytocin 5-10 units IM with the delivery of the anterior shoulder for the
third stage
• Frusemide 40mg IV in the third stage
Note: Avoid Ergometrine
Post-natal care
The patient must be closely monitored for at least 48 hours in a place where
maximum care can be given. This usually means in the labour ward or special
observation unit (SOU) which is a high dependency unit.



Consider discharge after 3-4 days after delivery if all is well
Discuss family planning
Discuss the surgical treatment of heart disease
5.7.3. Malaria in Pregnancy
Pregnant women are particularly at risk due to the lowered acquired partial
immunity during pregnancy. Adverse pregnancy outcomes include
spontaneous abortion, stillbirth, severe maternal anaemia and low birth
weight (weight <2500g).
Treatment for uncomplicated Malaria in pregnancy (MIP)
First-line treatment
• Quinine in the first trimester of pregnancy
• Artemether-Lumefantrine or Dihydroartemisinin-Piperaquine in the 2nd
and 3rd trimester.
Second-line treatment
• Quinine should be used in all cases of failure to 1 st line treatment.
Severe Malaria in pregnancy
Pregnant women, particularly in the second and third trimesters, are more
likely to develop severe malaria than other adults. Parenteral antimalarials
should be given to pregnant women with severe malaria in full doses without
delay and must be started with:
165
• Quinine in the first trimester and
• Injectable artesunate in the second and third trimesters
Intermittent Presumptive treatment (IPT)
Sulphadoxine-Pyrimethamine (SP) is the medicine of choice for IPT. One
adult treatment dose of 3 tablets should be given monthly (at least 4 weeks
apart) during the second trimester from 13-weeks gestation onwards. The
total number of doses recommended for the entire duration of pregnancy is
up to 6 doses, under direct observation (DOT) when possible.
5.7.4. Elimination of Mother-to-Child Transmission of HIV (EMTCT)
The four prongs of EMTCT:
 Prong 1 – Primary prevention of HIV among women of childbearing age
 Prong 2 – Prevention of unintended pregnancies among women living
with HIV
 Prong 3 – Prevention of HIV from mother to her infant
 Prong 4 – Provision of appropriate treatment, care and support to women
and children living with HIV and their families.
Prevention of Mother-to-Child Transmission
 There are better clinical and laboratory outcomes if HIV treatment is
initiated early.
 Initiate cART immediately among all pregnant or breastfeeding women
who test positive within Maternal Newborn Child Health (MNCH)
services.
 Treatment preparation and adherence counselling should be accelerated
so that it is completed on the same day where feasible.
 Initiation may be done by ART trained nurses/midwives within MNCH.
 Where there is no capacity within MNCH to initiate cART the pregnant
woman should be fast-tracked through the ART clinic.
 Start Cotrimoxazole among all HIV infected pregnant women regardless
of gestational age, CD4 count or WHO clinical staging.
 Viral load should be performed within 4 weeks before labour and delivery
to estimate the risk of transmission for all pregnant women on cART.
 At 6 weeks postnatal, check CD4 count and if >350cells/ul on two results,
Cotrimoxazole may be discontinued.
Combination antiretroviral therapy (cART) for eMTCT
First-line cART
166


For ARV naïve or sure of tail coverage 1 st line cART is TDF + XTC +
DTG - alternative regimen is
TDF + XTC + or EFV400 or TDF + XTC + ATV-r (or LPV-r) or ABC
+3TC +ATV-r (or LPV-r) or ABC + 3TC + DTG
For previous single dose Niverapine (sdNVP) exposure; or Niverapine
(NVP) monotherapy exposure, or unsure of tail coverage 1 st line cART is
TDF + XTC + DTG - alternative regimen is TDF + XTC + ATV-r (or
LPV-r) or ABC + 3TC + ATV-r (or LPV-r).
Second- line cART
 DTG and NNRTI –based first-line regimens can be substituted by AZT
+3TC + LPV-r (or ATV-r)
167
EMTCT in Pregnancy and Women of child-bearing age
Description
1st
Trimester
2nd Trimester
3rd Trimester
Labour and
HIV-Negative Female of child-bearing
age
Screen for Hep-B, Syphilis; if +ve treat
client +ve partner
Counsel and Initiate PrEP if eligible
Counsel client and partner on HIV
combination prevention
• Provide condoms or information on
where to access
condoms, including female condoms
• Refer to youth-friendly services for
more comprehensive
sexual information, including HIV
prevention
• Retest for HIV every 3 months
Screen for Hep B, Syphilis
If +ve treat client + partner
Counsel and Initiate PrEP if eligible
Counsel client and partner on HIV
combination prevention
• Provide condoms or information on
where to access
condoms, including female condoms
• Refer to youth-friendly services for
more comprehensive
sexual information, including HIV
prevention
• Retest for HIV every 3 months
Screen for Hep B, Syphilis
If +ve treat client + partner
Counsel and Initiate PrEP if eligible
Counsel client and partner on HIV
combination prevention
• Provide condoms or information on
where to access
condoms, including female condoms
• Refer to youth-friendly services for
more comprehensive
sexual information, including HIV
prevention
• Retest for HIV every 3 months
Do HIV test if done >6 weeks
168
HIV-Positive Female of child-bearing age
Counsel and continue/Initiate ART
Screen for Hep-B, Syphilis and OIs; if +ve
treat client + partner
• At ANC1, for known +ves on ART,
check if VL was done: if >3 months
retest, if >3 months repeat, and
thereafter every 3 months
• For those who initiate ART in ANC do
VL at 3 months, thereafter retest every
3 months
Provide condoms or information on
where
to access condoms, including female
condoms
Counsel and continue/Initiate ART
Screen for Hep B, Syphilis and OIs, if +ve
treat client + partner
• At ANC1, for known +ves on ART,
check if VL was done: if >3 months
retest, and thereafter every 3 months
• For those who initiate ART in ANC do
VL at 3 months, thereafter retest
every 3 months
Provide condoms or information on
where
to access condoms, including female
condoms
Counsel and continue/Initiate ART
Screen for Hep B, Syphilis and OIs, if +ve
treat client + partner
• Check if VL was done/do if not
done and if >3 months repeat
• Repeat viral load 1- 4 weeks before
delivery
Provide condoms or information on
where
to access condoms, including female
condoms
Counsel and continue/Initiate ART
delivery
Management of HIV-exposed infants
a)High-risk HIV exposed infants
1. Born to women with established HIV infection and has received less than
12 weeks of cART at the time of delivery or
2. Born to women with established HIV infection with viral load >1000
copies/ml within the four weeks before delivery:
Management
• Start or continue cART immediately for the mother and all exposed infants
to be put on AZT/3TC+NVP for 12 weeks.
Note: The use of NVP is only for prophylaxis in infants and treatment for up
to 2 weeks of age in absence of Raltegravir.
b)
High risk exposed infants
1. Born to women with established HIV infection not on cART;
2. Born to known HIV positive woman who refuses cART.
Management
• Start or continue cART immediately/continue counselling for the need to
start therapy. Suggest to start cART with the possibility of stopping after
delivery (Option B) while counselling continues toward the mother
accepting lifelong cART (Option B+).
• Prophylactic ART (AZT/3TC+NVP) until confirmed final outcome HIV
negative after complete cessation of breastfeeding.
Low-risk HIV exposed infants
1. Known HIV positive women on cART for more than 12 weeks, continue
cART for the mother and all exposed infants to be put on AZT/3TC +NVP
for 6 weeks.
2. HIV negative mother with a known positive partner does a nucleic acid test
(NAT), if negative, continue pre-exposure prophylaxis (PrEP) and provide
HIV testing services every 3 months. If NAT on mother is positive do NAT
on the baby.
5.8. ABORTION
This is the expulsion of products of conception, usually before 24-weeks
gestation. The contents of conception may or may not be completely expelled.
It may be spontaneous or induced.
169
Clinical features
• Vaginal bleeding
• Ruptured membranes
• Expulsion of foetus
• Static uterine size (missed abortion)
• Abdominal pain/tenderness
• May have fever
Management
This depends on the type of abortion:
• Missed, incomplete, septic abortions need evacuation of the uterus
• Septic abortion needs aggressive management with antibiotics.
• For inevitable abortion await expulsion of a foetus or augment with
Oxytocin
• Infuse IV fluids as required
Emergency treatment
• Look out for signs of hypovolaemic shock and treat appropriately
• Where Manual Vacuum Aspiration (MVA) is indicated, provide pre-MVA
counselling on the procedure
• Monitor blood pressure, pulse and temperature
• Look for signs of anaemia
• Evacuate uterus, preferably by MVA
• Give Oxytocin 5-10Units IV
Supportive
• Provide psychological support to patient and care
• Treat infection with appropriate antibiotics
• Provide post-MVA counselling
• Provide family planning counselling
• Facilitate linkages to other reproductive health services.
5.9. MEDICAL ABORTION (TERMINATION OF PREGNANCY)
Description
Under the Termination of Pregnancy Act, Cap 304 of the Laws of Zambia,
termination of pregnancy (TOP) relates to an induced abortion when a
pregnancy is terminated by a registered medical practitioner if he/she and two
other registered medical practitioners, one of whom has specialised in the
branch of medicine in which the patient is specifically required to be examined
before a conclusion could be reached that the abortion should be recommended.
The Act provides the general framework under which a pregnancy can be
terminated.
170
According to the Act, an abortion in Zambia can be conducted under the
following circumstances:
i) Risk to the life of the pregnant woman, or
ii) Risk of injury to the physical or mental health of the pregnant woman, or
iii) Risk of injury to the physical or mental health of any existing children
of the pregnant woman greater than if the pregnancy were terminated,
or
iv) Substantial risk that if the child were born, it would suffer from such
physical and mental abnormalities as to be seriously handicapped.
Women eligibility:
i) If gestation ≤12 weeks; if the medical doctor, after consulting with a
second doctor or registered midwife, is satisfied that;
- Pregnancy was from rape or incest, or
- There is a substantial risk that the foetus would suffer from a severe
mental or physical abnormality, or
- The continued pregnancy would pose a risk to the mother’s physical or
mental health, or
- Continued pregnancy will significantly affect the social or economic
circumstances of the woman.
ii) If gestation ≥12 weeks; if the medical doctor, after consulting with a
second doctor or registered midwife, is satisfied that continuing the
pregnancy would endanger the mothers’ life, pose a risk of injury to the
foetus, or result in a severe foetal malformation.
Setting
• Public health facilities are legally obligated to provide abortion-related
services.
• Private health facilities registered with HPCZ and offering other RH
services can also offer abortion-related services.
• Procedure for TOP should be done in a hygienic environment by skilled
staff (medical doctors, midwives) trained in performing medical TOP.
General Measures
• All women undergoing TOP must have certificate of opinion A or B
completed not later than 24 hours after such termination in the case of
certificate B
• Provide pre-and post-termination counselling as essential
• Obtain consent from the woman for TOP and related procedures (e.g.
laparotomy, MVA, etc.).
• If the patient's age is below that of legal consent to a medical or surgical
procedure (less than 18 years of age), the parents or legal guardian approval
to terminate the pregnancy must be documented. The best interest of the
minor will take precedence over that of the parents or guardian.
171
• In the case of conflict between the woman and the partner/spouse, the
woman's decision takes precedence.
• For all patients, a pertinent medical history and physical examination
including a bimanual examination must be obtained and documented.
• Anti-D where available should be offered to non-immunized RH negative
women especially after the first trimester.
• Offer contraception post-TOP
• When a patient with a positive pregnancy test presents with vaginal
bleeding and/or pelvic pain, ectopic pregnancy should be considered and ruled
out urgently. Where necessary and available, the following tests could be done
a) Pregnancy test
b) Hb if the patient is clinically anaemia
c) Ultrasound scan to confirm gestation age, rule out abnormality where
indicated, rule out ectopic pregnancy where there is suspicion and to confirm
the completeness of uterine evacuation where necessary.
Referral
• If service not available (e.g. facility not accredited), refer to the designated
level of care as soon as possible (within 2 weeks)
• If gestation ≥20 weeks.
5.9.1.
Uterine Evacuation Procedures
5.9.1.1. For pregnancies up to 12 completed weeks of gestation, methods used
for evacuation include:
• Surgical (manual vacuum aspiration (MVA), electric vacuum aspiration)
• Medication (Mifepristone combined with Misoprostol, or Misoprostol
alone where mifepristone is not available).
General Measures:
• Confirm pregnancy with a urine test.
• Determine the gestational age with ultrasound. If ultrasound is unavailable,
use dates (LMP) and bimanual (pelvic) examination.
• If unsure of dates, or examination disagrees with dates, or uterus palpable
abdominally, or the woman is obese or difficult to examine, arrange preprocedure ultrasound.
• Ultrasound is mandatory if suspected ectopic pregnancy – refer if uncertain.
• Counselling.
• Outpatient procedure by nursing staff with specific training.
• Screen for STIs (if treatment needed, do not delay TOP).
• Arrange Pap smear if needed.
• Check HIV status, Hb and blood group (Rh).
• Counsel and start contraception post-TOP, before leaving the facility.
Arrange contraception follow-up.
172
Medicine Treatment
• Mifepristone 200mg PO immediately as a single dose.
Followed 24–48 hours later by:
• Misoprostol 800mcg PV or SL
If expulsion does not occur within 4 hours of Misoprostol administration, a
second dose of Misoprostol 400mcg PO or PV may be given.
Note:
• Allowing home use of Mifepristone and Misoprostol after counselling and
clinical evaluation at a health care facility can improve the privacy,
convenience and acceptability of services, without compromising on safety.
• Patient's instructions must include information about the use of medication
at home and symptoms of abortion complications and what to do in such
cases.
• Medical abortion and in particular, use of Misoprostol, for pregnancies over
12 weeks should be facility-based to facilitate the need for repeated.
• The patient must be informed that if the medical abortion fails, the surgical
method may be needed.
• The facility must provide an emergency contact on a 24-hour basis and must
assure referral for uterine aspiration if indicated for patients selfadministering misoprostol and/or mifepristone at home following clinical
evaluation and counselling at a health care facility.
• Healthcare providers should ensure that all victims of SGBV should be
linked to other supportive services including prevention and management
of STIs, HIV, unwanted pregnancy and need for Post Exposure Prophylaxis
(PEP), psychosocial counselling and shelter. Establish effective referral
systems through formalized agreements between stakeholders.
For pain:
After administration of Mifepristone, start:
• Paracetamol 1g PO 4–6 hourly when required to a maximum of 4 doses per
24 hours (Maximum dose: 15mg/kg/dose or 4g in 24 hours).
ADD
After expulsion is complete:
• Ibuprofen 400mg PO 8 hourly with or after a meal.
OR
173
5.9.1.2.
weeks:
TOP using manual vacuum aspiration (MVA) - if gestation >14
• Medical abortion or Dilatation and Evacuation (D&E) are the preferred
methods for evacuating the uterus in the second trimester after cervical
preparation/priming/ ripening.
• Misoprostol 400mcg PV 3 hours before vacuum aspiration of the uterus.
Note:
Cervical preparation (ripening/priming) is recommended for
a) Nulliparous women
b) Women less than 18 years old, and
c) All women at 12-14 weeks of gestation and above.
Routine analgesia for vacuum aspiration:
Consider para-cervical block if trained in the technique. All women undergoing
MVA for induced abortion must be offered para-cervical block.
Alternatively; Oral analgesia as required for 48 hours:
• Paracetamol 1g PO 4–6 hourly when required to a maximum of 4 doses per
24 hours, AND
• Ibuprofen 400mg PO 8 hourly with or after a meal.
For both medical and surgical TOPs (MVA):
In Rh-negative, non-sensitised women: Give Anti-D immunoglobulin 50–
100mcg IM preferably within 72 hours but may be given up to 7 days following
TOP.
Clinical protocols for post-operative care must be followed.
Review all patients after 7 days: if bleeding persists, arrange urgent ultrasound.
Referral
• If gestation ≥12 weeks.
• If gestation is uncertain.
• If any signs or symptoms of ectopic pregnancy or other early pregnancy
complications.
• Co-morbid conditions (heart disease, asthma, diabetes, anaemia, clotting
disorder, seizure disorder, substance abuse, hypertension).
• Large fibroids (may interfere with determining gestation age and/or MVA).
174
• Any signs of sepsis (tachycardia, hypotension, pyrexia, tachypnoea,
offensive vaginal discharge).
• If MVA not available or declined.
5.9.1.3. Late second trimester terminations (Therapeutic)
• TOP in the late second trimester is sometimes necessary. Termination done
in late second trimester should be done in obstetrics and gynaecology
sections of the hospital.
• All facilities should have clear and evidence-based protocols for TOP in the
late second trimester.
• Hospitalisation is required for all patients having a termination of
pregnancy in the late second-trimester abortion
• Bereavement counselling should be offered to all women undergoing TOP
in the late second trimester
Guideline:
1) Patient must be informed that should medical methods fail surgical methods
such as D & E may be needed and with a possibility of hysterectomy.
2) Expulsion of a live foetus is a possibility which fact must be discussed with
a patient.
5.9.2.
Post-abortion care (PAC)
PAC is safe when provided by a trained provider in an environment with
adequate hygiene and suitable equipment. All institutions offering PAC
services should be registered by appropriate regulatory authorities.
PAC can be provided from health levels as low as the health post (depending
on available skills and clients condition) up to tertiary level. All institutions
providing PAC should be guided by local protocols.
Emergency preparedness should be available in all facilities providing PAC.
All facilities should be able to stabilize, treat or refer patients with post-abortion
complications.
5.9.2.1. Emergency treatment
• Assessment should include assessment of vital signs and indication of how
clinically stable the patient is.
• Any patient discovered with a life-threatening condition such as shock,
ectopic pregnancy, sepsis or haemorrhage should have resuscitative
measures instituted immediately.
175
• Physical examination should include a pelvic examination noting any
vaginal discharge, vaginal bleeding, uterine size and presence of retained
products of conception (RPOCs). Signs of infection including fever, foulsmelling discharge, and tender uterus should also be documented.
• If an infection is suspected, appropriate laboratory specimens should be
taken but should not delay the initiation of treatment.
• Appropriate laboratory tests such as HB, blood grouping and cross
matching and any other tests indicated by the medical condition of the
patient should be done.
For the management of complications, refer to local protocols or the National
Standards & Guidelines for Comprehensive Abortion Care in Zambia.
5.10. MENSTRUAL DISORDERS
It is important to decide whether the menstrual disorder is truly a menstrual
disorder or not. The menstrual history, type of contraceptive used, history of
previous pregnancies, kind of discharge and related issues must be noted. The
abdomen must always be examined for tenderness or masses. The vagina should
also be examined and the condition of the cervix and any discharge should be
noted.
5.10.1. Dysmenorrhea
Description
This is severe pain associated with the menstrual cycle and is usually referred
to as period pains. This may be due to gynaecological or non-gynaecological
reasons.
There are two types:
• Spasmodic
• Congestive
5.10.1.1 Spasmodic
This occurs primarily in teenagers and young multiparous women, but is not
uncommon in elderly multiparous women.
Management
• Empathy and reassurance.
• Simple analgesics such as Aspirin 600mg orally 3-4 times daily or
Paracetamol 1g orally 3 - 4 times daily.
176
• In severe pain, Ibuprofen can be given 400mg twice daily throughout the
menstrual period.
• If pain is very severe, contraceptive pills may be used for 6 months
Congestive
• In this condition, the pain is due to an organic cause such as pelvic infection,
fibroids and endometriosis
Management
• Empathy and reassurance
• Simple analgesics such as Aspirin 600mg orally 3 - 4 times daily or
Paracetamol 1g orally 3 - 4 times daily
In severe pain, Ibuprofen can be given 400mg twice daily throughout the
menstrual period
• Treat the cause
5.10.2. Amenorrhoea
Definition
It is a condition characterised by the absence of menstruation.
There are two types i.e.
5.9.2.2 Primary amenorrhoea
This is when a girl has not menstruated by 16 years of age. Genitalia and
secondary sexual development may be normal or abnormal.
Management
• Reassure patient
• Refer to specialist if the patient does not have menstrual periods by 18 years
of age or absence of secondary sexual development.
5.9.2.3 Secondary amenorrhoea
This is a condition where menstruation stops for more than 3 consecutive
months. The most common cause of amenorrhoea is pregnancy. Some of the
other causes include:
• Stress
• Anxiety
• Significant loss of weight
• Contraceptives e.g. Mini-pill, Depot contraceptive injection; other
hormonal medicines such as Danazol (alternative: 17-beta-hydroxy-2,4,17alpha-pregnadien-20-yno[2,3-D] isoxazole) LHRH analogue.
A vaginal examination and laboratory investigations may help give the
diagnosis.
177
Management
If pregnancy is not present, and amenorrhoea persists for one year or more
without obvious disease refer to a Specialist.
5.10.3.
Oligomenorrhoea
Definition
This is when the menstrual cycle is more than 35 days. Usually, it has no
consequences unless the patient complains of infertility. If infertile for more
than one year, refer the patient to a Specialist.
5.10.4.
Polymenorrhoea
Definition
This is when the menstrual cycle is less than 21 days. Wrong calculation of
menstruation dates could be mistaken for polymenorrhoea. It can also be caused
by meno- metrorrhagia. When no abnormalities are detected, the pill may be
helpful. Refer to specialist if the pill does not help.
5.10.5.
Meno-metrorrhagia
Definition
This is when the menstrual period lasts more than 7 days.
Often there is also excessive blood loss and irregular vaginal blood loss.
Diagnosis
A good history taking (i.e. family planning method used etc.) is very important.
The differential diagnosis includes:
• Abortion
• Carcinoma of the cervix
• Fibromyomata
• Dysfunctional Uterine Bleeding (DUB)
• Ectopic pregnancy
Treatment
• Progestogens treatment
• Fractionated Dilatation and Curettage (D & C) may be needed for older
women or non-response to hormone therapy.
5.10.6. Post-menopausal bleeding
The most common cause is carcinoma of the cervix and uterus. A vaginal
examination, including speculum, should be done to exclude carcinoma of the
178
cervix and uterus. Hormones and antibiotics should not be given before this is
done.
Refer the patient to a Specialist.
179
6. RESPIRATORY TRACT DISEASES
Respiratory tract diseases include upper and lower and lower respiratory tract
infections or as well as obstructive airway diseases.
6.1. RESPIRATORY TRACT INFECTIONS
6.1.1. Upper Respiratory Tract Infections
Respiratory Tract Infections involve lower and upper or both respiratory tract
systems. These include the common cold, bronchitis and pneumonia
6.1.1.1. Common Cold
Description
This is a self-limiting disease caused by viruses and allergies. If it is viral, it is
a highly infectious condition
comprising mild systemic upset and prominent nasal symptoms
Clinical Features
Symptoms
• Running nose/nasal congestion
• Cough
• Irritation of the throat
• Fever
• Sneezing
Complications
• Lower respiratory tract infection (see 6.1.2)
• Bronchitis and pneumonia
Treatment
• Analgesics;
Aspirin, 600mg 3 - 4 times daily or paracetamol, 500mg - 1g orally 3 - 4
times daily in adults, children; paracetamol, 10 - 20mg/kg 3 times daily
• Nasal decongestants
• Cough mixtures may offer symptomatic relief
• Take plenty of fluids
Note: (i) Aspirin is not recommended for children under 16 years.
(ii) Antibiotics are not indicated
180
Supportive
• Advise patient to take plenty of fluids
6.1.1.2. Laryngotracheobronchitis
Description
This is an inflammation of the larynx, trachea and bronchus following an acute
viral respiratory infection.
Clinical features
Symptoms
• Pain in the larynx
• Hoarseness of voice
• Irritating persistent cough
• Shortness of breath
• Fever
Signs
• Stridor
• Persistent or recurrent laryngitis
Treatment
Analgesics in early stages
• Paracetamol, 500mg – 1g orally 3 – 4 times daily in adults, 10 – 20mg/kg
orally 3 – 4 times daily in children
Supportive
• Give more fluids and humidification
6.1.2. Lower Respiratory Infections
These conditions include Pneumonia and Bronchitis.
6.1.2.1. Pneumonia
Description
This is an inflammation of the lungs usually caused by
Streptococcus pneumoniae, Mycoplasma pneumoniae and Staphylococcus
aureus Haemophilus Influenzae type B and atypical organisms such as Jiroveci
pneumonia.
Clinical features
These are usually of sudden onset.
181
Symptoms
• Fever
• Dry or productive cough
• Chest pain
• Chills
• Breathlessness
• Children may be unable to drink or breastfeed
Signs
• Bronchial breathing
• Drowsiness
• Increased respiration rate
• Cyanosis may be present
• Flaring of nostrils
• Chest indrawing
• Increased pulse rate
• Crepitations
• Breath sounds may be reduced
• Sputum may be "rusty".
Complications
• Septicaemia
• Lung abscess
• Emphysema
• Heart failure
• Meningitis
Diagnosis
This is based on clinical findings but may be supported by radiological
examinations which show lobar and bronchial pneumonia.
Treatment
Some patients will need admission particularly if there is cyanosis or
complications.
• Benzylpenicillin 1-2MU intravenously 6 hourly for 5 days adults, children
25,000-50,000 units/kg intravenously/intramuscularly in 4 divided doses
for 7 days (as soon as the symptoms and respiratory rates are controlled
change to oral medication i.e. Amoxycillin 250mg for adults and 125
mg/5ml in children) or
• Ceftriaxone 1g - 2g daily adults, children 20 50mg/kg daily
intravenously/intramuscularly for 7 days. if allergic to penicillin or
182
• Erythromycin 500mg adults, orally 6 hourly for 7 days, children 2030mg/kg in 4 divided doses for
7 days
• Oxygen is indicated if respiratory distress or cyanosis is present
Non-opiate analgesics; Paracetamol 500mg - 1g orally 3 - 4 times daily adults,
children 10-20mg/kg orally 3 - 4 times daily.
Refer early to a specialist if the patient is not rapidly improving with antibiotic
treatment.
6.1.2.2. Pneumonia in Children
If a child has a cough or difficulty in breathing, then he/ she may have a
respiratory tract infection.
Clinical features
May include:
•
Fast breathing
•
Chest in drawing
•
Stridor in a calm child
•
Wheezing
It is important to count the respiratory rate of the child.
If the child is :
Fast breathing is:
2 months up to
12 months
50 breaths per minute or
more
12 months up to 5 years
40 breaths per minute or
more
Classification
• No pneumonia cough or cold: a child is classified as having no pneumonia
cough or cold if there are no signs of pneumonia
• Pneumonia: a child is classified as having pneumonia if there is fast
breathing accompanying wheeze or cough Severe pneumonia: a child is
classified as having severe pneumonia if there is chest in-drawing or stridor
in a calm child.
Treatment
No pneumonia cough or cold:
•
If coughing for more than 21 days, refer for assessment,
183
•
•
If wheezing give oral Salbutamol
Follow up in 5 days if not improving.
PNEUMONIA
Give an Appropriate Oral Antibiotic
FOR PNEUMONIA, ACUTE EAR INFECTION OR VERY SEVERE DISEASE:
AMOXYCILLIN
Give three times daily for 5
days Amoxicillin
AGE or
WEIGH
T
2 months
up to
12
months
(4-<10 kg)
12 months
up to
5 years
(10-19kg)
ERYTHROMYCIN
Give four times daily for 5 days 2nd-LINE ANTIBIOTIC Erythromycin
TABL
ET
SYRU
P
250m
g
125 mg
per 5
ml
AGE
WEIGHT
or
TABLET
250 mg
SYRUP
125/5
ml
2 months up to
4
months 4-<6kg)
1 /2
1
1 /4
5 ml
10 ml
4 months up to
12 months (6<6kg)
12 months up to
5 years (1019kg)
184
2.5 ml
1 /2
5 ml
1
10 ml
FOR DYSENTERY:
1st –LINE ANTIBIOTIC:- Nalidixic Acid 2nd –LINE ANTIBIOTIC:- Cotrimoxazole
NALIDIXIC ACID
Give four times daily for 5 days
AGE
WEIGHT
or
TABLET
CO-TRIMOXAZOLE
(Trimethoprim + Sulphamethoxazole)
AGE
OR
WEIGHT
250 mg
ADULT
TABLET
PEDRIATIC
TABLET
SYRUP
20
mg
Trimethoprim
+100
mg
+2Sulpha- methoxazole
40 mg
80 mg
Trimethoprim
+400 mg
Sulphamethoxazole
Trimethoprim
200 mg
Sulphamethoxazole
per
5 ml
2 months
2 months
up to
up to
4
12
months
months
(4-<6
kg)
1 /4
(4-10
kg)
4 months
2 months
up to
up to
12
5 years
months
(10-19
(6-<10
kg)
12
months up
to
5 years
(10-19
kg)
1 /2
2
5 ml
1
3
7.5 ml
kg)
1 /2
1
185
FOR CHOLERA: *1st-LINE ANTIBIOTIC: - Erythromycin
*Note: Remember that the most important life-saving interventions for cholera patients is
immediate and appropriate rehydration.
Give Salbutamol
For wheezing with no respiratory distress (chest in-drawing)
SALBUTAMOL
Give three times a day
2 months up to 12
months (<10kg)
1 /2
12 months up to 12 months
(10-19kg)
186
1/
4
GIVE THESE TREATMENTS IN CLINIC ONLY
•
•
•
Explain to the caretaker why the drug is given
Determine the dose appropriate for the child’s weight (or age)
Use a sterile needle and syringe. Measure the dose accurately
Give an Intramuscular Antibiotic
•
For severe pneumonia or severe disease or very severe febrile illness
FOR CHILDREN REFERRED
URGENTLY WHO CANNOT
TAKE AN
• Give first dose intra-muscular Chloramphenicol and refer
child urgently to hospital
• If chloramphenicol is not available, give the first dose of
Benzylpenicillin IM and refer urgently
IF REFERRAL
POSSIBLE
IS
NOT
• Repeat the Chloramphenicol injection every 12 hours for 5
days
• Then change to an appropriate oral antibiotic to complete
10 days of treatment
• Do not attempt to treat with Benzylpenicillin alone.
AGE or WEIGHT
2 months up to
4 months (4-<6kg)
4 months up to
9 months (6-<8kg)
9 months up to
12 months (8-<10kg)
12 months up to
12 months(10-<14kg)
3 years up to 5 years
(14-19kg)
CHLORAMPH
ENICOL
Dose: 40 mg per
kg Add 5.0 ml
sterile water to
vial containing
1000 mg=5.6
ml at
180 mg/ml
BENZYLPENICILLIN
To a vial of 600 mg (1,000,000 units):
Add
2.1 ml of sterile water=2.5 ml
at 400,000
1.0 ml = 180
mg
0.8 ml
1.5 ml = 270
mg
1.0 ml
2.0 ml = 360
mg
1.2 ml
2.5 ml = 450
mg
1.5 ml
3.5 ml = 630
mg
2.0 ml
187
6.1.2.3. Aspiration pneumonia
More common in new-born babies especially in premature, respiratory
distress, chronically ill, chronic aspirators, post vascular operations
Treatment
• Gentamycin, 5mg/kg twice a day or I.M 10 mg once daily
• Ciprofloxacin, 10mg/Kg body weight 3 times daily, the benefit must
outweigh the risk but may be used for 5 to 17-year-olds.
6.1.2.4. Atypical Pneumonia
Signs and symptoms of pneumonia plus extra-pulmonary signs such as
arthritis, splenomegaly caused by Mycoplasma, Chlamydia, PCP.
Treatment
• Erythromycin 500mg orally QID for 14 days for Chlamydia
• Co-trimoxazole 960mg every 12 hours for 21 days in combination
with a steroid i.e. Prednisolone for
PCP starting with 40mg per day and reducing by
5mg every 3 days for adults
• For children above 4 weeks to adults 120mg/Kg body weight in 2 to
4 divided doses for 21 days
6.1.2.5. Obstructive Airway Disease
Obstructive Airway Disease can be upper or lower.
6.1.2.5.1.
Upper airway obstruction
The condition is caused by a viral infection or inhaled foreign body. The
main symptom is stridor.
When it is caused by viral infection the condition is called Croup. Croup
is fairly common and is frightening to parents. Usually, admission is
advisable. If the infection has caused epiglottitis, the obstruction may be
so severe as to necessitate tracheal incubation and antibiotics may be
required.
Treatment
• Chloramphenicol 50 - 100mg/kg intravenously in 4 divided doses
daily for 5 days
• Humidified oxygen (30 - 40% concentration)
• Dexamethasone 0.3mg/kg intramuscularly stat, Repeat after 6 hours.
188
• Naso-tracheal intubation or tracheostomy if an obstruction is severe
Stridor due to Diphtheria
In stridor due to diphtheria, an examination of the throat will reveal a
white membrane. Diphtheria infection is uncommon nowadays.
Treatment
• Benzyl Penicillin IM/IV 25,000 - 50,000 units/kg intravenously in 4
divided doses for 5 days
Prevention
• Diphtheria can be effectively prevented by active immunisation in
childhood
Stridor due to an inhaled foreign body is usually preceded by sudden
chock whilst eating a meal or playing with small objects.
Treatment
• Remove foreign body
Stridor due to inhaled Paraffin
Symptoms
• Smell of paraffin
• Cyanosis
• High respiratory rate
• Tachycardia
• Tachypnoea
Treatment
DO NOT INDUCE VOMITING!
• Give milk
• Hydrate
• Give Oxygen
• Antibiotic prophylaxis with Amoxycillin 125mg/5ml taken
3 times a day.
Advice to patients
• Do not put paraffin in soft drink containers
•
Clearly label paraffin containers
189
6.2. LOWER OBSTRUCTIVE AIRWAY DISEASES
Obstructive airway diseases are a spectrum of diseases characterised by
obstruction of the lower airway with asthma and emphysema on either end
of the spectrum.
6.2.1. Asthma
Description
This is an acute or recurrent reversible obstructive airway disease
characterised by increased responsiveness of the tracheobronchial tree to
a variety of stimuli resulting in obstruction of the lower airways. The
attacks can be precipitated by allergy, (especially to a cat, horse or other
animal hair or pollens), infection or exercise. The obstruction can be
reversed by treating with beta-adrenergic agents such as Salbutamol.
Clinical features
Symptoms
• Wheezing
• Difficulty in breathing
• Coughing
• Restlessness
Signs
• Prolonged expiration
• Cyanosis if severe
• Rapid pulse
• Dehydration
• Sticky, clear sputum
• Wheezing
If the pulse is over 120/min, the patient's condition must be regarded as
serious and hospital admission is urgent.
Chest X-ray is necessary to exclude cardiac problems, pneumothorax or
foreign body in the upper airway.
Treatment
Early vigorous treatment is important. The longer treatment is delayed
the more difficult it is to reverse the process.
Mild Cases
190
These cases are not in acute distress and the pulse rate is usually not above
100/min. They are not cyanosed or dehydrated.
•
Salbutamol, 2-4mg orally three times daily
•
Salbutamol inhaler 2 puffs stat. Followed by 1 puff 4-6 hourly
Note: Inhaled corticosteroids e.g. Beclomethasone, 2 puffs given 10
minutes after salbutamol inhaler may be used.
The patient must be taught how to use the inhaler. Check that he can use
it correctly. If he/she cannot learn, use oral Salbutamol 4mg 3 times daily
though. it may cause extrapyramidal symptoms.
Severe cases
The features are:
• Difficulty in breathing
• Sitting up in distress
• Difficulty in talking and drinking
• Pulse over 120/minute
• Exhaustion‚
• Dehydration
• Cyanosis
• Silent chest on auscultation
The patient should be admitted to hospital urgently for close monitoring.
The patient should be nursed on a propped up bed and be given a sputum
cup.
The pulse and blood pressure should be checked every hour.
If possible, Peak Expiratory Flow Rate (PFR) should be measured hourly.
Treatment
• Intravenous fluids, 3 litres per day; (1 litre 0.9% sodium chloride and
2 litres 5% dextrose)
• 20mmol potassium chloride added to 1L of any of the above fluids in
24 hrs
• Humidified oxygen through a mask, 3 litres/minute
• Nebulised salbutamol 5mg stat given through a nebuliser. Follow this
first dose by nebulised salbutamol 2.5mg every 4 hours
• Hydrocortisone, 200mg intravenously 4 hourly
• Start oral prednisolone, 30mg once daily for 5 days
191
• Aminophylline 250mg IV over 5-10mins followed by a maintenance
dose of 100mg (less than 500mg over 24hours) 8 hourly over 24 hours.
If the patient has heart disease, liver disease or is taking beta-blockers
reduce the dose of aminophylline. Always give oxygen with
aminophylline. Patients who have taken oral aminophylline in the last
8 hours should not be given the loading dose.
• Antibiotics. If there is evidence of bacterial infection give an
appropriate antibiotic.
Treatment
The asthmatic child
Important clinical signs to record
• Pulse rate
• Respiratory rate
• Degree of breathlessness
• Use of accessory muscles of respiration
• Amount of wheezing
• Degree of agitation
• Level of consciousness
Role of investigations
• Pulse oximetry (SaO2 <92%)
• PEF (>33%)
• CXR (Complications, life-threatening asthma)
• Blood gases (Raised pCO2)
Initial treatment of acute asthma
In children >2 years
• Salbutamol 100mcg inhaler 2 – 10 puffs every 10 to 20 minutes
• Salbutamol via nebuliser if SaO2 < 92% 2.5 - 5 mg every 20-30
minutes
• Ipratropium bromide
• If symptoms are refractory to 2 agonist treatment 250-500 mcg/dose
mixed with salbutamol
• Steroid therapy
Steroid tablets Give Prednisolone early in the treatment of acute asthma
attacks 20 mg in children 2-5 years, 40 mg in children >5 years.
• Intravenous steroids
For severe exacerbations or children who are vomiting. Hydrocortisone
4 mg/kg 4 hourly
• Inhaled steroids. No evidence of additional benefit.
Can be maintained in children already on long term therapy
192
Second-line treatment of acute asthma
• In children > 2 years, IV Salbutamol in severe cases with no response
to inhaler therapy 15 mcg/kg over 10 minutes; 1-5 mcg/kg/min
infusion.
Monitor ECG, Potassium levels.
• In children > 2 years, cont. IV aminophylline; No benefits for mild to
moderate asthma, common and troublesome side-effects 4mg/kg over
20 minutes, 1 mg/kg/hour infusion
Monitor: ECG, Potassium levels, Aminophylline serum levels
See Appendix A (Controlling steps).
6.2.2. Emphysema
This is an irreversible obstruction of the airways characterised with the
destruction of the alveoli and bronchioles by fibrosis.
Clinical Features
Symptoms
• Severe shortness of breath with slight exertion
• Recurrent coughs
• Slight wheezing
• Barrel chest
Signs
• Barrel chest
• Clubbing of fingers
• Hyper inflated lungs on X-ray
• Air trapping on X-ray
Treatment
Treat causes of exacerbations of the conditions
• Hydrocortisone 200mg intravenously 4 hourly for 24 hours and
maintain on oral Prednisolone 30mg on alternate days
• Suction of the fluid from the airway
• Give an appropriate antibiotic i.e. Erythromycin
• 500mg while awaiting sputum results
Supportive
• Give up the habit that caused the emphysema e.g. stop smoking,
193
• Give oxygen.
Prevention
• Stop smoking
• Reduce industrial exposure
• Wear gas masks
194
7.
CARDIOVASCULAR DISORDERS
7.1. HYPERTENSION
Hypertension is one of the leading public health problems
worldwide. It is often asymptomatic, easily detectable, and
potentially easily amenable to treatment. Yet, if left untreated it
often leads to fatal complications. Since hypertension tends to be
asymptomatic, public education about the dangers of hypertension
plays a significant role in the overall management of hypertension.
Description
The World Health Organization defines grade 1 hypertension as
office blood pressures ranging from 140–159 mm Hg systolic or 90–
99 mm Hg diastolic, grade 2 hypertension as pressures of more than
100 mm Hg systolic or 100–109 mm Hg diastolic. The baseline
figures do not apply to children, diabetic Mellitus patients, renal
patients and pregnant women (hypertension in pregnancy, refer to
chapter 5.6). The frequency of hypertension increases with age.
Risk Factors with Adverse Prognosis:
• Black race
• Youth
• Male sex
• Persistent diastolic pressure greater than 115mmHg
• Smoking
• Excess alcohol intake
• Hypercholesterolemia
• Diabetes Mellitus
• Obesity
Classification of Hypertension
The National Heart, Lung, and Blood Institutes classify blood
pressure as normal, prehypertension, hypertension stage 1, and
hypertension stage 2.
195
1.
Normal (optimal)
Systolic (mmHg)
Diastolic (mmHg)
< 120
2.
< 80
Hypertension
Stage
Severity
Systolic
Range
(mmHg)
Prehypertension
I
II
mild
(moderatesevere)
Diastolic
Range
(mmHg)
130-139
140 - 159
80 - 89
90 – 99
> or = 160
> or = 100
From the Seventh Report of the Joint National Committee on Detection,
Evaluation, and Treatment of High Blood Pressure
Aetiology of Hypertension
• Primary (essential) Hypertension
• Secondary Hypertension
• Systolic Hypertension
• Hypertensive Crises (acute hypertension)
7.1.1.
Primary Hypertension
This is hypertension for which there is no specific identifiable cause. About
90% of hypertension cases fall under this category.
7.1.2.
Secondary Hypertension
This is hypertension due to a specific underlying condition or conditions.
Some of the causes include the following:
• Renal Parenchymal Diseases e.g. glomerulonephritis
• Renovascular Diseases e.g. atherosclerotic (mainly older men) and
fibroplastic (mostly younger women) diseases.
• Endocrine Diseases e.g. Pheochromocytoma, Cushing’s Syndrome.
• Cardiovascular Disease e.g. coarctation of the aorta
• Pregnancy (gestational hypertension)
• Drugs e.g. oral contraceptives, erythropoietin, steroids
196
7.1.3.
Systolic Hypertension
7.1.4.
Hypertensive Crises
These are clinical situations associated with blood pressure rising to levels
usually above 130 mmHg diastolic. There are two types: hypertensive
emergency which is associated with acute end-organ dysfunction (brain, heart
and kidneys). In this setting, there is a high risk of causing irreversible damage
to the brain, heart or kidneys if blood pressure is not controlled within an hour
or so. Hypertensive urgency is the other setting with equally markedly raised
BP but without significant signs or symptoms suggestive of end-organ
damage. In this setting BP reduction may be gradual over 24 hours. Other
terms used in this situation are accelerated malignant hypertension depending
on retinal findings during funduscopy examination. If there are haemorrhage
and/or exudates on the retina then it is referred to as accelerated hypertension
but if there is papilloedema then it is called malignant hypertension. From a
therapeutic point of view, both forms are treated in practically the same way.
Clinical Features
Hypertension is usually asymptomatic until when it has caused complications
and damage to target organs. At this point, the symptoms are thus associated
with the affected organ.
Symptoms
• Palpitations
• Dizziness
• Shortness of breath
• Blurred vision
Signs
• Tachycardia
• Cerebral vascular insufficiency
• Lung crepitations
• Hypertensive retinopathy
Complications
• Atherosclerosis
• Cerebral vascular insufficiency
• Cerebral vascular accident
• Congestive heart failure
• Coronary artery disease
197
•
•
•
•
Peripheral vascular insufficiency
Dissecting aortic aneurysm
Hypertensive retinopathy
Hypertensive nephropathy and renal failure
Management
• To document the presence or absence of end-organ damage.
• To exclude the possibility of a secondary cause of hypertension and other
co-morbidities.
Investigations
• Urinalysis
• Fundoscopy
• Electrocardiogram
• Chest x-ray
• Echocardiogram
• Urea, creatinine and electrolytes
• Random blood sugar
• Lipid profile
• Abdominal ultrasound
Treatment
The objective of treating high blood pressure is both to prevent and lower
related complications such as strokes, renal failure and heart failure.
Hypertension not responding to treatment should be referred to a specialist
for further investigations.
Prevention
•
The initial approach to treatment is that of lifestyle modification.
i.e. smoking cessation, weight reduction to optimal weight, BMI less than 25,
regular exercise, reduction in alcohol intake, dietary modifications
(e.g. salt reduction, fat-free diet.).
Drugs
Goals of therapy –blood pressure less than 140/90 mmHg and less than
130/80 mm Hg for those with diabetes and chronic kidney disease.
Stepwise approach, use of a combination of drugs for better effect.
Step 1.
Start with Diuretics (e.g. Amiloride + Hydrochlorothiazide
(5/50mg) orally daily) OR
198
Calcium channel blockers (Nifedipine retard 20mg two times daily orally or
Amlodipine 5 -10 mg once daily orally; OR
Angiotensin-converting enzyme inhibitors (Captopril 25-50mg two or three
times daily orally, Enalapril 5-20mg once daily orally) . Those who cannot
tolerate ACEI may be given Losartan potassium 50-100mg once daily orally.
Step 2.
Use a combination of drugs from different groups (e.g. Diuretic + ACEI, or
Calcium channel blocker + ACEI, or, Diuretic + Calcium channel blocker).
Step 3.
Use a combination of Diuretic + ACEI + Calcium channel blocker
Step 4.
If not controlled as above, optimize the dose, add further diuretic therapy
OR
Alpha-adrenoceptor blocker (Prazosin 0.5mg two to three times daily orally
– initial should be at bedtime to avoid postural hypotension – then increase to
1-3 mg two to three times daily after three to seven days, maximum daily dose
20mg)
OR
Add beta-adrenoceptor blocker e.g. Atenolol 50-100 mg once daily orally,
OR
Hydralazine 25-50 mg two or three times daily orally.
Beta-blockers are no longer preferred as a routine initial therapy for
hypertension, however, can be used in younger people, patients with
cardiovascular risk or existing ischemic heart disease, those with
contraindications or intolerance to ACEI, ARB as adjunctive drugs to other
antihypertensive.
Hypertensive Emergency – very severe to malignant hypertension:
• Start with Labetalol 50 mg IV over at least a minute, repeated after five
minutes if necessary, maximum dose is 200mg
OR
• Hydralazine 10 mg IV stat followed by 5 mg IV every 30 minutes until
diastolic BP is 110 mm Hg or less
• Frusemide 40-80mg IV may be used as adjunctive therapy as a stat dose.
199
7.2.
CONGESTIVE HEART FAILURE
Description
This is a condition in which an abnormality of cardiac function is responsible
for the inability of the heart to meet the requirement of the metabolising
tissues.
Causes
Some underlying causes of heart failure:
• Valvular Heart Disease e.g. mitral valve disease
• Viral Myocarditis
• Congenital Heart Disease
• Hypertension
• Cardiomyopathies
• Pericardial diseases
• Ischaemic heart disease
• Arrhythmias
• Thyroid dysfunctions
• Anaemia
Precipitating Causes
• infection including endocarditis
• anaemia
• thyrotoxicosis
• arrhythmias
• systemic hypertension
• pulmonary embolism
• pregnancy
Forms of Heart Failure
• Diastolic
• Systolic
• High output
• Low output
• Right-sided
• Left-sided
Clinical Features
Symptoms
• Fatigue
• Shortness of breath at rest or on exertion
200
•
•
•
•
•
•
Orthopnoea
Paroxysmal Nocturnal Dyspnoea
Cough
Anorexia
Swollen legs
Abdomen distension
Signs
• Neck vein distension or raised JVP
• Basal crepitations (rales)
• cardiomegaly
• S3 gallop
• Hepatomegaly
• Hepatojugular reflux
• Pulmonary oedema
• Tachycardia
• Oedema
• Pleural effusion
• Ascites
Management
Investigations
• Chest x-ray
• ECG
• Echocardiogram
• Full Blood Count
• Liver function test
• Urea, creatinine, electrolytes
• Urinalysis routine and microscopic
• HIV test
The following tests are not routinely ordered unless there is a clinical
indication:
• cardiac enzymes
• Thyroid function tests
• Cardiac catheterization
Treatment
This is divided into 3 parts:
• Treat precipitating cause
201
• Correct underlying cause e.g. valve replacement in
Mitral valve disease
• Control congestive heart failure state
General Measures
• Restrict physical activities
• Restrict salt and water
• Lifestyle modification (no smoking, no alcohol, -nutrition)
New York Heart Association functional class (NYHA)
1.
Class I - Asymptomatic
2.Class II - Symptomatic on moderate exertion
3.Class III - Symptomatic on mild exertion
4.Class IV - Symptomatic at rest
Drugs
1.Class I
Asymptomatic
• Most patients do not require medicine but will require lifestyle
modifications.
2. Class II
• Captopril 12.5mg to 25mg twice a day orally
OR
• Lisinopril 5 - 10mg daily orally
OR
• Enalapril 5mg to 20mg daily orally (if the patient develops a persistent
dry cough replace with Losartan 50mg daily orally.
• Hydrochlorothiazide 25mg daily or oral Frusemide 20 – 40mg daily
• Beta-blockers (Carvedilol 3.125mg twice daily orally, increase the dose
at least every two weeks to 25mg twice daily if the patient is over 85kg
then maximum dose 50mg twice daily or use Metoprolol 50 – 100mg
daily orally)
3. Class III
• Captopril 25mg 2 to 3 times daily OR
• Lisinopril 10mg to 20mg daily OR
• Enalapril 5mg to 20mg daily orally (if the patient develops a persistent
dry cough
• Frusemide 40mg – 80mg twice a day orally (monitor potassium levels)
• Digoxin 0.125mg – 025mg daily
202
• Isosorbide dinitrate 5mg to 10mg twice a day + Hydralazine 25 – 50mg
twice daily orally if patient cannot tolerate ACE inhibitors
• Acetylsalicylic Acid (ASA) 75mg once daily
4. Class IV
• Captopril 25mg 2 to 3 times daily OR
• Lisinopril 10mg to 20mg daily OR
• Enalapril 5mg to 20mg daily orally (if the patient develops a persistent
dry cough replace with Losartan 50mg daily orally.
• Frusemide I.V. 40mg – 80mg once or twice a day (monitor potassium
levels)
• Digoxin 0.125mg – 025mg daily
• Isosorbide dinitrate 5mg to 10mg twice a day + Hydralazine 25 – 50mg
twice daily orally if patient cannot tolerate Ace inhibitors
• Spironolactone 25 – 50 mg once or twice daily orally
• Acetylsalicylic Acid (ASA) 75mg once daily
• B-blockers should not be used in Class IV CHF.
7.2.1.
Cardiogenic shock
Description
This is an advanced cardiac failure with inadequate peripheral perfusion
Clinical Features
Symptoms
• As above but severe
Signs
• BP less than 90mmHg systolic
• Pulse feeble or non-detectable
• Cold extremities
• Peripheral cyanosis
• Poor urine output
• Comatose
Treatment
• ICU care
• Oxygen
• Dopamine 5-10 micrograms per kg/body weight per minute; I.V. infusion
(dilute 400mg in 500ml of 5% Dextrose; infusion rate to be calculated
according to body weight)
203
• Dobutamine 5-10 microgram/kg/min IV infusion
• Acetylsalicylic Acid (Aspirin) 75mg once daily
If BP goes above 90mmHg treat as class IV
7.2.2.
Dilated Cardiomyopathy
Description
This is characterised by dilatation of both left and right ventricles and poor
contractility.
Some identifiable causes include pregnancy, radiotherapy, chemotherapy,
alcohol, association with HIV infection.
Clinical features:
Fatigue
• Signs of left-sided or biventricular failure
• Murmurs
• arrhythmias.
Diagnosis
CXR, ECG, Echocardiography.
Treatment
Treat as in heart failure, see above.
7.2.2.1
Hypertrophic Cardiomyopathy
Description
This is characterised by marked asymmetric hypertrophy of left ventricle
without an obvious cause. It is usually inherited in an autosomal dominant
manner.
Clinical Features Symptoms
• Chest pains
• Fatigue
• Syncope attack
204
• Palpitations
Signs
• Arrhythmias
• Systolic murmur on left sternal border
• Sudden death
Diagnosis
• Echocardiography
• ECG
• Holter Monitor
Treatment
Propranolol, 10-40mg 3-4 times a day OR
Atenolol 25-50mg daily, (use with care in people who have asthma.
Occasionally, beta-blockers may make the patient feel tired or lethargic, cause
sleep disturbance, and pain in the hands and feet during cold weather).
Acetylsalicylic Acid (Aspirin) 75mg once daily.
7.2.2.2
Restrictive cardiomyopathy
Description
This is a condition of restricted ventricular filling resulting in diastolic heart
failure.
Clinical Features Symptoms
•
•
•
•
Fatigue
Abdominal distention/ discomfort
Oedema
Shortness of breath
Signs
• Elevation of jugular venous pressure with inspiration Hepatic
enlargement
• Ascites
205
• Fourth heart sound
Management
• ECG
• Echocardiogram
• Transvenous endocardial biopsy
Treatment
• There is no specific treatment.
• Cardiac failure (refer to chapter 7.2) and embolic problems should be
treated.
• Cardiac transplantation should be considered in severe cases.
206
7.3. MYOCARDIAL INFARCTION
Description
This is necrosis of a part of the cardiac muscle due to sustained myocardial
ischemia of more than 30 minutes and formation of thrombus within the
affected coronary artery.
Clinical Features
Symptoms
• Chest pain of greater severity and duration (>30 minutes) than in angina
but similar in nature
• Shortness of breath
• Sweating
• Extreme distress
• Abdominal pain
Some infarcts may be painless e.g. in the elderly and diabetics
Signs
• Distress
• Coldness and clamminess of extremities
• Tachycardia
• Raised or lowered blood pressure
• Cyanosis
• Arrhythmias
Complications
• Arrhythmias
• Heart Failure
• Hypotension
• Pericardial effusion
• Systemic embolisation
• Dressler’s syndrome (autoimmune syndrome- pericarditis, pneumonia,
pleurisy)
• Papillary muscle rupture
• Cardiogenic shock
• Rupture of the ventricular septum or ventricular wall
• Left ventricular aneurysm with Left Ventricular Failure
Management
• Investigations
207
•
•
•
•
•
•
•
•
•
ECG
Cardiac enzymes (Troponin T and I, CPK) – MB fraction
Echocardiography
Chest X-Ray
Urea and Electrolytes (U + E)
Full Blood Count
Erythrocyte Sedimentation Rate
Lipid profile
Myocardial perfusion scan
Diagnosis requires at least two of the following:
• History of ischaemic-type chest pain
• Evolving ECG changes
• A rise and fall in cardiac enzymes
Treatment
Keep under close observation and refer for management in the intensive care
unit.
Drugs
• Oxygen by mask or nasal catheter
• Access to an IV line
• Morphine 5-10mg intravenously at about 1mg per minute
• Glyceryl trinitrate 0.5mg sublingually
• Aspirin 300mg orally to chew stat
• Streptokinase, 1,500,000 units in 100ml of 0.9% saline intravenously over
1 hour (If the presentation is less than 12 hours after onset of pain) (Do
not give if there is a stroke or active bleeding in the last 2 months, blood
pressure > 200mmHg, surgery or trauma in last 10 days, bleeding
disorder, pregnancy, diabetic retinopathy, previous streptokinase or any
thrombolytic treatment in the last 5 days to 1 year).
• Heparin, 5000 I.U intravenously stat, then 1000 I.U hourly intravenously
for 24hrs for 3-5 days.
• Low Molecular weight heparin Enoxaparin 1mg/kg SC twice daily.
• ACE inhibitors i.e. Enalapril 5- 10mg daily.
• Beta-blockers e.g. Atenolol 50mg daily.
• Antacids e.g. IV Ranitidine 50mg three times daily.
• Laxatives, e.g. Lactulose 15 – 30ml two-three times daily orally.
• Diazepam, 5mg orally daily.
• Aspirin, 75-150mg daily.
208
• Statins e.g. Simvastatin 10 – 20mg daily orally
• Isosorbide dinitrate, 10mg three times a day
If pain continues;
• Nitroglycerine I.V. infusion 10 – 200 mcg /minute
• Refer for PCI (coronary intervention).
Supportive
• Reassure the patient and carers
• Continuous ECG monitoring
• 24-hour bed rest
• 24-hour Temperature, Pulse and Respiratory rates
• 24-hour blood pressure readings
• Daily 12 lead ECG, Chest X-Ray, cardiac enzymes, and U&E for 2-3 days
• Refer the patient for coronary angiography, refer to a specialist as soon
as possible.
Prevention
• Low lipid diet
• Stop smoking
• Regular exercise
7.4. ANGINA PECTORIS
Description
This is chest pain due to myocardial ischemia.
Clinical features
Symptoms
• Chest pain: The pain is central/retrosternal and may radiate to the jaw/or
arms.
• Breathlessness
Signs
• Fourth heart sound
• Anxiety
• There may be no signs
Management
209
•
•
•
•
•
•
ECG
Exercise ECG
Echocardiogram
Lipid profile
Myocardial perfusion scan
Coronary angiography
Treatment
Drugs
• Aspirin, 75 - 300mg orally once daily
• Glyceryl trinitrate, 0.3 - 1mg sublingually, repeated
as required or
• Isosorbide dinitrate, 5 - 10mg sublingually, 30 120mg orally in 2 divided
doses daily.
• Atenolol, 50 - 100mg orally daily
• Nifedipine (immediate-release) 10 - 20mg orally once or twice daily
• Statin e.g. Simvastatin, 10 – 20mg daily orally
Surgery
• Coronary angioplasty
• Coronary by-pass
Supportive
• Manage co-existing conditions
• Stop smoking
• Weight loss
• Encourage regular exercise
7.5. PULMONARY OEDEMA
Description
Acute left ventricular failure due to various cardiac conditions or due to
severe mitral stenosis with pulmonary hypertension
Clinical features
Symptoms
• Breathlessness
• Wheezing
• Profuse sweating
• Productive cough
• Bloodstained sputum
210
Signs
• Paroxysmal dyspnea
• Anxiety
• Bloodstained sputum
• Tachypnoea
• Peripheral circulatory shut down
• Crackles
• Wheezing
Diagnosis
Investigations
• Arterial gases
• Pulse oximetry
• Chest X-Ray
• Central venous pressure
• ECG
• Echo
• Cardiac enzymes
Treatment
The patient should be placed in a sitting position.
Medication therapy
• Frusemide, adults: initially 40mg to 120mg I.V. Stat, thereafter continue
Frusemide 20mg-daily orally or 40mg on alternate days
• Morphine 5mg to 10mg I.V. slowly
• Oxygen 60% via a mask
• Glycerol trinitrate, 0.3 - 1mg sublingually, repeated as required
• Underlying conditions should be treated.
7.6. RHEUMATIC FEVER
Description
This is an inflammatory disease that occurs in children and young adults (5 15 years) as a result of infection with group A streptococcus. It affects the
heart, skin, joints and central nervous system. Pharyngeal infection with
group A streptococcus may be followed by the clinical syndrome of
rheumatic fever. This is thought to develop because of an autoimmune
reaction triggered by the infective streptococcus and not due to direct
infection of the heart or the production of a toxin.
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Clinical features
Revised Jones criteria for the diagnosis of rheumatic fever
Major
• Carditis
• Polyarthritis
• Sydenham’s chorea
• Erythema marginatum
• Subcutaneous nodules
Minor
• Arthralgia
• History of rheumatic fever
• Fever
• Increased P-R interval on ECG
• Raised ESR
• Increased C-reactive protein
Evidence of streptococcal infection
Raised ASO titre (or increased titre of other specific
antistreptococcal antibodies) Positive throat culture
Diagnosis
Investigations
• Throat swab
• Serology
• ESR
• ECG
• Echocardiography
Diagnosis is made based on two or more major criteria or one major plus two
or more minor criteria plus evidence of antecedent streptococcal infection.
Treatment
Drugs
• Benzathine penicillin 0.6–1.2 mega units IM stat
OR
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• Phenoxymethylpenicillin 500mg orally 4 times daily for 7 days. For
recurrences, 250mg daily until the age of twenty or for 5 years after the
latest attack
OR
• Erythromycin, 250 – 500mg orally 4times daily for 7 days. For
recurrences, 125 – 250mg once daily until the age of twenty or for 5 years
after the latest attack
• Prednisolone 1 – 2mg/kg per day divided into 4 equal doses for 10 days
(in severe carditis)
Chronic rheumatic heart disease
More than 50% of those who suffer acute rheumatic fever with carditis will
later develop chronic rheumatic valvular disease predominantly affecting the
mitral and aortic valves.
Complications
• Congestive cardiac failure
• Pulmonary oedema
Management
Investigations
• Chest X-Ray
• ECG
• Echocardiography
Treatment
• Treat underlying complications
• Give prophylaxis against recurrent rheumatic fever with Benzathine
Penicillin 1.2 – 2.4 MU monthly for life
• Give prophylaxis against infective endocarditis
Refer
• For further evaluation, if the patient has significant heart murmurs
• All patients with increasing cardiac symptoms.
7.7. CARDIAC ARRHYTHMIAS
Description
This involves the disorders of cardiac impulse formation, automaticity,
impulse conduction, heart rate and abnormal ectopic activity.
213
Clinical features
Symptoms
• Palpitation
• Missing heartbeats
• Dizziness and syncope
• Difficulty in breathing
Signs
• increased or decreased pulse and heart rate (more than 100 or less than
60/min)
• Irregular pulse and heart rate
• Features of heart failure
• Bradyarrhythmias (sinus bradycardia, sinus node dysfunction,
atrioventricular blocks), heart rate <55/min
• Tachyarrhythmias (atrial fibrillation and flutter, supraventricular and
ventricular tachycardia). Premature atrial and ventricular contractions.
Investigations
• ECG
• Ambulatory ECG monitoring (Holter)
• Serum electrolytes level
• Echocardiography
• Stress ECG test, TFTs
Management
Bradyarrhythmias:
• Sinus bradycardia – no treatment required unless symptomatic, remove
offensive drugs (e.g. B-blockers, digoxin) if symptomatic –Atropine
0.6mg IV or cardiac pacing
• Sinus arrhythmia – no treatment needed
• Atrioventricular block 1st degree – treat underlying causes (carditis, drug
toxicity).
• Atrioventricular block 2nd degree – may require cardiac pacing, refer to
a specialist
• Atrioventricular block 3d degree – cardiac pacing, refer to a specialist.
Tachyarrhythmias:
• Supraventricular tachycardia ‡
Heart rate 150–220/min on ECG narrow QRS complex strictly regular
tachycardia – start with vagal stimulation (unilateral carotid massage,
Valsalva manoeuvre), the drug of choice is Adenosine 6mg IV push, if no
214
response, give 12mg IV push. Other drugs – Verapamil 2.5-5.0mg IV
slowly. Diltiazem 15-20mg IV over 2 min. Propranolol 1-2 mg IV bolus.
Refer to a specialist.
• Ventricular tachycardia
Heart rate 130-180/min, on ECG wide QRS complex not strictly regular
tachycardia– if the patient’s condition is unstable – defibrillate at 50-100
+ 200.
• If the patient is stable, pharmacological treatment: Amiodarone 300mg
IV over 10 min, followed by infusion at 1mg/min for 6 hours; Lignocaine
100mg IV bolus, followed by infusion of 4 mg/min for 30 min, 2 mg/min
for 2 hours, then 1 mg/min.
215
In case of multifocal Ventricular tachycardia use Magnesium sulfate1-2 g
IV.
Correct reversible causes: hypokalemia, digoxin toxicity.
Atrial fibrillation:
• Rate control can be achieved by Digoxin 0.125-0.25 mg once or two
times daily orally, Verapamil 40 to 80mg three times daily orally,
Diltiazem 60mg three times daily orally
• Amiodarone 200mg three times daily orally 1st week, then reduce to
200mg two times daily (maintenance dose 200 to 400mg daily)
• Electrical cardioversion (refer to a specialist)
• Anticoagulation therapy (to reduce the risk of systemic embolization) –
Aspirin 75-150mg once daily orally, Warfarin 2.5-10mg once daily
orally (to maintain INR 2,5 to 3,5).
• Use Warfarin, if no INR available, Aspirin 75-150mg orally once daily.
Premature atrial contractions
No treatment required. If symptomatic: B-blockers (e.g. Propranolol 2040mg orally 2-3 times daily, Verapamil 40-80mg orally 2-3 times daily.
Premature ventricular contractions
No treatment if asymptomatic, if symptomatic or frequent – Beta-blockers
(Propranolol 40-80mg three times daily orally), Amiodarone 200mg three
times daily orally for 5-7 days, then reduce to 200mg two times daily
(maintenance dose 100-200mg daily).
Monitor for possible side effects: Thyroid function test, LFTs, consult
ophthalmologist and CXR once a year.
7.8. INFECTIVE ENDOCARDITIS
Description
This is a microbial infection of the endocardium, which may result in valvular
damage, myocardial abscess, or mycotic aneurysm.
Causes
Streptococcal species (especially Streptococcus viridans),
Staphylococci, HACEK group, Enterococci.
216
Predisposing factors
Preexisting valvular disease, congenital heart disease, dental and surgical
procedures, intracardiac devices (prosthetic valves, pacemaker),
intravascular catheters, intravenous drug abuse.
Can be acute and subacute.
Clinical features
Symptoms
• Fever
• Night sweats
• Arthralgia
• Malaise
• Weight loss
• Dyspnea
Signs
• Fever
• Peripheral stigmata (splinter haemorrhages, Osler’s nodes, Janeway
lesion, Roth’s spots)
• Pallor and jaundice
• Heart murmurs
• Features of heart failure
• Embolic phenomena
• Splenomegaly
• Hematuria
Diagnosis
Duke’s criteria:
1.Criteria for Infective Endocarditis
A. Two major criteria or
B. One major and three minor or
C. Five minor criteria
2.Major criteria
A. Positive blood culture X >2 (typical microorganisms for infective
endocarditis)
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B. Positive Echocardiographic study ( vegetation on the valves, wall
abscess, new valve regurgitation)
3.Minor criteria
A. Predisposing heart condition or injected drug user
B. Febrile syndrome
C. Vascular phenomena (embolism, CNS haemorrhage, conjunctival
haemorrhage, Janeway lesion)
D. Immunologic phenomena (glomerulonephritis, Rheumatoid factor,
Osler’s nodes, Roth’s spots, false-positive VDRL test)
E. Microbiologic evidence (positive blood culture, but not typical
microorganisms)
F. Echocardiography: suggestive but not positive for infective
endocarditis
Management
Investigations
• Blood culture
• Echocardiography
• FBC
• Urinalysis and microscopy
• U/E, LFTs
Treatment
1. Appropriate antibiotics: Penicillin G 10-20 MU /day IV in divided doses
(4 times)or Ampicillin 8-12 g/day IV for 4 weeks and Gentamycin 1
mg/kg ( up to 80 mg) 3 times IV daily 2-4 week. If Staphylococcus
aureus: Oxacillin or Vancomycin IV
2. Bed rest
3. Treat heart failure and arrhythmias
4. Surgery - valvular replacement (indications: refractory heart failure,
uncontrolled infection, fungal infections with large vegetation >10mm
in size, recurrent systemic embolism, suppurative pericarditis, mycotic
aneurysm or rupture of sinus of Valsalva)
Prophylaxis
Conditions in which prophylaxis is recommended:
1. Prosthetic cardiac valves
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2. Previous infective endocarditis
3. Certain types of Congenital Heart Diseases (unrepaired cyanotic CHD,
complete repair of CHD with prosthetic material or device for first 6
months; repaired CHD with the residual defects at the site of prosthetic
valve or patch)
4. Cardiac transplantation with valvulopathy No prophylaxis is
recommended for most dental, GIT and GUT procedures, with acquired
valve disease, hypertrophic cardiomyopathy, a pacemaker or coronary
by-pass surgery.
Prevention
Good oral hygiene, regular dental review
Antibiotics for prophylaxis, 1 hour before procedure:
Oral:
Amoxycillin 2 g (adult), 50 mg/kg (children) or
Cephalexin 2g (adult), 50 mg/kg (children) or Azithromycin 500 mg (adult),
15 mg/kg (children)
Parenteral
Amoxycillin 2 g IM/IV (adult), 50 mg/kg (children)
Cefazolin or Ceftriaxone 1 g IM/IV (adult), 50 mg/kg
(children)
Clindamycin 600 mg IM/IV (adult), 20 mg/kg (children).
7.9. CARDIOPULMONARY RESUSCITATION AND ADVANCED
CARDIAC LIFE SUPPORT
7.9.1. Basic life support (BLS)
Goals of resuscitation – to maintain cerebral perfusion until the
cardiopulmonary function is restored.
Important change: A-B-C changed to C-A-B (circulation first).
1. Check responsiveness by gently shaking the patient.
2. Call for help, fetch defibrillator and oxygen and airway adjuncts,
resuscitation kit.
219
3.
4.
5.
6.
Position the patient on a firm flat surface.
Open the patient’s airway and assess for the presence of respiration.
Check circulation (palpate for a carotid pulse), if not present start CPR.
Initiate chest compressions (position both hands over the lower part of
the sternum and compress at the rate of 30 compressions/ 2 breaths).
At the rate of 100 chest compressions/min, depth in adults 2 inches,
infants 4 inches.
7. Once the patient is intubated, ventilation can be at a rate of 12-15 per
minute without pausing for compressions.
7.9.2. Advanced cardiac life support
Advanced cardiac life support (ACLS) is an extension of BLS and usually is
implemented by a team leader with the use of necessary facilities.
1. IV access with IV fluid e.g. before NS
2. Attach defibrillator-monitor.
3. Assess cardiac rhythm.
If Ventricular tachycardia or ventricular fibrillation:
•
Defibrillate
•
Epinephrine 1mg IV push, repeat every 3-5 minutes
•
Consider antiarrhythmic drugs – Amiodarone 300mg IV push or
Lignocaine 1.0-1.5mg/kg IV push
OR
Magnesium sulfate 1-2g IV push
Identify and treat reversible causes 4 “T”: Tension pneumothorax,
Thrombosis (coronary and pulmonary), Tamponade cardiac, Toxins; 4 “H”:
Hypovolemia, Hypoxia, Hypothermia, Hypo/Hyperkalemia; Acidosis.
If asystole:
•
Continue CPR
•
Epinephrine 1 mg IV push every 3-5 minutes until there is a cardiac
rhythm or CPR is stopped
•
Treat reversible causes (see above)
•
Atropine is no longer recommended for asystole and PEA (Pulseless
Electrical Activity).
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•
Termination of resuscitation: terminate resuscitation after 5 cycles of
CPR and defibrillation, also if the prognosis of the underlying
condition is poor.
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8.
MALIGNANCIES
8.1. LEUKAEMIAS
Description
These are diseases characterised by the proliferation of a single malignantly
transformed progenitor cell in the haemopoietic system. Acute leukaemia if
untreated has a rapidly fatal course. Chronic leukaemia has a more prolonged
course but patients invariably die from it. Leukaemia is classified according
to the morphological cell type involved and the speed of evolution of the
disease:
•
Acute Lymphoblastic Leukaemia (ALL)
•
Acute Myelogenous Leukaemia (AML)
•
Chronic Lymphatic Leukaemia (CLL)
•
Chronic Myeloid Leukaemia (CML)
8.1.1. Acute Lymphoblastic Leukaemia (ALL)
Description
The proliferation of lymphoid cells in the bone marrow.
Clinical features
Any age may be affected but commonly 4 to 8-year-olds. Male to female
ratio is 1:1.
Symptoms
Fatigue, headache, palpitations, bleeding into skin, nose mucous membrane,
infections such as sore throat pneumonia and bone pain.
Signs
Bone tenderness, splenomegaly, lymphadenopathy, pallor and bruises.
Signs include pallor, bruising, petechial haemorrhage, bleeding gums and
gum hypertrophy, lymphadenopathy, splenomegaly and/or hepatomegaly,
haemorrhage in the optic fundi. Hard enlarged testicles indicate that the
testes have become infiltrated with leukaemic tissue.
Opportunistic infections do occur.
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Management
Diagnosis
a) Full blood count which shows a normocytic/normochromic anaemia
b) The white cell count may be normal or raised (normal
4 -11 x 109/L 50,000 or more
c) The platelet count is usually reduced (normal 150
- 4000 x 109/L) below 150 /9/L
d) Characteristic leukaemic cells in blood and bone marrow
e) The CSF prepared sediment may show blast cells if meningeal leukaemia
is present.
f) The peripheral smear show lymphoblast.
Treatment:
Supportive care
•
Blood and platelet transfusion, I.V.
•
Appropriate antibiotics at the first sign of infection
•
Correction of dehydration, treatment of hyperuricemia arising from
chemotherapy with Allopurinol and I.V. fluids
•
Barrier nursing, prophylactic antibiotics e.g. Co-trimoxazole to prevent
pneumocystis carinii (jiroveci)
•
Emotional support
Chemotherapy
This is done in 3 steps:
i) Remission induction:
Vincristine 2mg/m2 I/V every 1-2 weeks
Prednisolone 60mg/m2 daily
Daunorubicin 40mg-75mg/m2 daily
ii) CNS prophylaxis:
Intrathecal Methotrexate 5mg/kg weekly Cranial irradiation.
iii)Maintenance chemotherapy:
Mercaptopurine (daily)100-200mg daily
Children 2.55/kg body weight per day.
Methotrexate Children 12.5mg/Methotrexate
(weekly)
Vincristine and prednisolone (monthly) For 2 –3 years.
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Prophylaxis
Methotrexate
10mg
12.5mg
15mg
Danorubicin
10mg
12.5mg
16mg
Ara-c
20mg
25mg
30mg
Bone marrow should be performed in all suspected cases and will show more
than 5% lymphoblasts.
A lumbar puncture may be done. If meningeal leukaemia is suspected this
will show blasts in the CSF.
Relapse is common in blood, CNS or testis.
Prognosis
Is better in children where the cure rates for children are 70 – 90%; it is very
poor in adults where 20% cure rates have been recorded. Worse prognosis in
blacks.
8.1.2. Acute Myelogenous Leukaemia
Description
The proliferation of myeloid cells in the bone marrow and blood. This has
got unfavourable prognosis and increases with age.
Clinical features
1. Marrow failure causes
a. Anaemia
b. infection often positive bleeding from the gums
c.disseminated intravascular coagulation
2. Leukaemic infiltration
a. bone pain, tender sternum
b.CNS signs (cord compression, cranial nerve lesions)
c.Gums hypertrophy, testes, orbit ((proptosis)
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d.Hepatosplenomegaly
e. Lymphadenopathy
f. Skin and peri-anal involvement
3. Constitutional features
a. malaise
b. weakness
c. fever
d. polyarthritis
Management
Diagnosis
i) The white cell count is variable
ii) Bone marrow biopsy – diagnosis depends on this.
Treatment
Chemotherapy
1. Very intensive. The main drugs used include daunorubicin, cytosine
100-200mg per square meter for 5 days I/V or subcutaneous.
arabinoside and thioguanine 2mg/kg body weight daily.
Long term maintenance is generally considered to be less effective
Bone marrow transplant (BMT) – allogeneic transplant is possible in
acute conditions.
Intrathecal prophylaxis.
2.
Supportive care
i)
Blood and platelet transfusion
ii)
Barrier nursing
iii)
I.V. antibiotics
8.1.3. Chronic Lymphatic Leukaemia (CLL)
Description
This is the infiltration of the bone marrow and blood relatively mature
lymphocytes common in people above 60 years of age.
Clinical features
Symptoms include:
225
i) Bleeding
ii)Weight loss
iii)Infection
iv)Anorexia
v)Lethargy
vi)Fever and sweating
Signs include:
i) Enlarged, rubbery, non-tender nodes
ii)Hepatosplenomegaly
iii)Pallor
Complications
i) Auto-immune haemolysis
ii) Infection - bacterial or viral (mostly of the respiratory tract).
iii) Bone marrow failure
Diagnosis
i) FBC Mild anaemia – normocytic/normochromic type.
ii)The white cell count is > 15 x 109/L of which more than 60% are
lymphocytes
iii)The platelet count is usually normal in the early stages
iv)Bone marrow shows mainly more mature lymphocytes
Treatment
Chemotherapy
This is not always needed but may postpone marrow failure. Chlorambucil
0.1–0.2mg/Kg body weight orally daily is used to decrease the lymphocyte
count. Prednisolone 60mg/m2
Steroids are used if there is auto-immune haemolysis.
i)
ii)
Transfusions
Prophylactic antibiotics
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8.1.4. Chronic Myeloid Leukaemia (CML)
Clinical features
Description
This is the infiltration of the bone marrow and blood with relative mature
myeloblasts.
It accounts for 15% of leukaemias and often occurs in middle age of 45 - 55
with a slight male predominance.
Symptoms
a) Symptoms of anaemia
b) A large spleen (swelling of the abdomen)
c) Priapism
d) Gout
e) Sweating, fever and loss of weight
f) Bruising
Signs
Pallor, splenomegaly, hepatomegaly, bleeding into the mucous membrane
and there may be evidence of infection.
Management
Diagnosis
i) FBC which shows raised WBC (often .100 x 109/L)
ii) Low Hb
iii)Platelets may be raised normal or reduced.
v)Abundance of neutrophils in the blood film but the whole spectrum of
myeloid precursors including a few blast cells
vi)Bone marrow may present with the whole spectrum of myeloid precursors
including a few blast cells.
Mega karyocyte may be abundant.
vii)Philadelphia chromosome on chromosome preparation
viii)Levels of Vitamin B12 and B12 binding proteins are elevated
Treatment
i) Treatment of choice is Hydroxyurea 30-50mg/kg body weight in two
divided doses or Busulfan 2-4mg daily
227
ii) Allogeneic bone marrow transplant
iii)
Splenectomy can reduce discomfort, radiation to the spleen may
reduce discomfort.
Prevention
Avoid predisposing factors such as radiation chemicals e.g. Benzene and
other drugs like Phenylbutazone.
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8.2. LYMPHOMAS
Description
Lymphomas are malignant tumours of the lymphoreticular system and are
classified into Hodgkin's disease and non- Hodgkin's lymphoma.
8.2.1.
Hodgkin's Disease (HD)
The lymphoid tissue on biopsy shows malignant lymphoid cells with Dorothy
Reed Sternberg cell.
Classification
•
Nodular Lymphocyte predominant HD
•
Classic HD
1. Nodular Sclerosing
2. Mixed Cellularity
3. Lymphocyte depleted
4. Lymphocyte rich
Symptoms and Signs
•
Fever, weight loss, and night sweats
•
Loss of appetite
•
Pruritis
•
Pallor
•
Pain in the infiltrated tissue (Alcohol-induced)
•
Enlarged lymph nodes
•
Hepato-splenomegaly
•
Weight loss.
Diagnosis
•
History and physical examination
•
Excision biopsy
•
FBC, ESR, LDH, LFTs, U/Es
•
CXR
•
Abdominal Ultrasound
•
CT chest abdomen and Pelvis
•
HIV and CD4 count
For advanced-stage disease bone marrow aspiration and trephine
229
Treatment
The choice of treatment is determined by the stage of the disease. It consists
of a combination of radiotherapy and chemotherapy.
Stage I & II – 4 cycles of chemotherapy plus involved-field radiation therapy.
Stage III & IV – 6 – 8 cycles of combination chemotherapy plus radiotherapy
for residual localized disease.
Chemotherapy ABVD regimen:
•
Doxorubicin 25mg/m2 D1 & 15 IV
•
Bleomycin 10 units/m2 D1 & 15 IV
•
Vinblastine 6mg/m2 D1 & 15 IV
•
Darcabazine 375mg/m2 D1 & 15 IV Repeat every 28 days
COPP Regimen
Cyclophosphamide
Oncovin
Procarbazine
Prednisolone
600 mg/m2
1.4 mg/ m2
100 mg/m2
40 mg/m2
Days 1 and 8
Days 1 and 8
Days 1-10
Days 1-14
8.2.2. Non-Hodgkin's Lymphoma
This is a heterogeneous group of lymphoreticular malignancies. These
lymphomas may be associated with HIV/ AIDS.
Symptoms and signs
See under Hodgkin's disease.
Classification
•
Low-grade Aggressive
•
Highly Aggressive
Diagnosis
•
As for Hodgkin's Lymphoma HIV and CD4 count
•
Conduct immunohistochemistry and flow cytometry where possible
•
Lumbar puncture for the highly aggressive
230
Treatment
Low-grade Stage I & II - curative radiotherapy or watchful waiting, if they
are HIV negative.
Low-grade Stage III & IV - watchful waiting or with single or combination
chemotherapy and radiotherapy
Single agents
•
•
Fludarabine 25mg/m2 IV D1-5 for every 28 days OR
Chlorambucil 2-4mg orally daily or 30-60mg orally every 2 weeks.
Combination chemotherapy regimens:
•
•
CVP
CHOP
Aggressive Disease
Stage I & II - 3 cycles CHOP Chemotherapy PLUS consolidation
radiotherapy to 30 - 36Gy
Stage III & IV - CHOP chemotherapy 6 -8 cycles and radiotherapy to local
residual disease
Regimens
CHOP
•
Cyclophosphamide 750mg/m2 D1 IV
•
Doxorubicin SOmg/ m2 D1 IV
•
Vincristine 1.4mg/ m2 D1 IV (maximum of 2mg)
•
Prednisolone 100mg PO D1 - 5
Repeat every 21 days
CVP
•
Cyclophosphamide 400 - 600mg/ m2 D1 IV
•
Vincristine 1.4mg/ m2 D1 IV (maximum of 2mg)
•
Prednisolone 100mg PO D1 - 5
Repeat every 21 days
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Highly Aggressive NHL
8.2.3. Burkitt’s Lymphoma
Description
This is a highly aggressive NHL, which presents mainly in children, with a
jaw swelling, abdominal mass, ovarian mass and CNS involvement.
Diagnosis
i) History and physical examination
ii) Biopsy of the tumour plus Lymph node
iii) FBC, ESR, LFTs, U/Es, LOH
iv) Bone Marrow Aspiration and/ or Trephine biopsy
v) CXR
vi) CT scan of the abdomen and pelvis
vii)
HIV testing and CD4 especially in adults
viii)
CSF examination is done at the first intrathecal treatment
Treatment
This is associated with tumour lysis syndrome, so IV pre-hydration and
allopurinol must be given before starting chemotherapy
Regimen
Patients with localised disease receive 3 cycles of CODOXM.
Patients with multiple site involvements are treated with CODOX-M
alternating with IVAC and intrathecal therapy for 4 cycles each.
CODOX-M and CODOX-M alternating with IVAC
CODOX-M
•
•
•
•
Cyclophosphamide 800mg/m2 D1 and 200mg/m2 D2-5 IV
Vincristine 1.5mg/m2 D1 IV (max 2mg)
Doxorubicin 40mg/m2 D1 & 8 IV
Methotrexate 1.2g/m2 continuous IV infusion on D10, then 240mg/m2
IV each hour over 23hrs
232
•
Folinic Acid 192mg/m2 IV D11 starting from the 12th hour of
Methotrexate infusion, then 12mg/m2 IV every 6hrs for next 48hrs
•
G-CSF support starting on day 13 until G-CSF (Filgrastim) support
starting on day 13 until granulocyte count is (Filgastrim) above
1X109/L granulocyte count is above 1X109/L
CNS prophylaxis
• Cytarabine 30mg/m2 IT D1 & 3
• Methotrexate 12mg/m2 IT D15 (Not more than 20mg total dose)
• Hydrocortisone 20mg/m2 D1, 3 and 15
• Folinic Acid
IVAC
• lfosphamide 1.5g/ m2 IV D1 - 5
• Etoposide 60mg/ m2 IV D1 - 5
• Cytarabine 2g/ m2 IV every 12hrs for D1 and 2
• Filgrastim start on D7 till absolute granulocyte count is over 1x 109/ L.
CNS prophylaxis
• Methotrexate 12mg/ m2 IT D5
• Folinic Acid 15mg orally stat on D6.
8.3. CARCINOMA OF THE BREAST
Description
This is a malignancy of the breast and there are various types.
Clinical features
Symptoms and Signs
1. Lump in the breast
2. Nipple discharge
3. Change in breast size
4. Nipple inversion
5. Skin changes - orange-like appearance (‘peau d' orange’)
6. Axillary, Infraclavicular and supraclavicular lymphadenopathy
Diagnosis
i) History and physical examination
ii) Bilateral Mammography
iii) Core biopsy or excision biopsy, do oestrogen and progesterone receptor
status and if possible Her2 neu status
233
iv) CXR
v) FBC and ESR, LFTs, U/Es, LDH
vi) For patients with raised ALP, LDH S/S of bone or liver involvement
do ultrasound of abdomen and bone scan.
Treatment
This depends on the stage of the disease.
i) Early Breast cancer
•
Breast-Conserving Treatment: wide local excision with axillary
dissection, then Adjuvant Radiation therapy and/or chemotherapy
•
Modified Radical Mastectomy with an axillary dissection.
Adjuvant Chemotherapy and radiotherapy will depend on the
histopathological findings (stage).
ii) Locally Advanced Breast Cancer – must be treated with all
modalities (Surgery, Chemotherapy and
Radiation therapy)
iii) Metastatic Breast Cancer – Chemotherapy and where indicated
hormonal therapy.
Treatment Regimens
1. Chemotherapy
• AC – Doxorubicin 60mg/m2 IV D1 and Cyclophosphamide 600mg/m2
IV D1 repeat every 21 days for 4 cycles
OR
• CAF – Oral cyclophosphamide 100mg/m2 D1 – 14, Doxorubicin
30mg/m2 IV D1 and D8, and 5 Fluorouracil 500mg/m2 IV D1 and D8.
Repeat every 28 days for 6 cycles
OR
• FAC – 5 Fluorouracil 500mg/m2 IV D1 &8, Doxorubicin 50mg/m2 IV
D1, and cyclophosphamide 500mg/m2 IV D1. Repeat every 21 days for
6 cycles
OR
• CMF - Cyclophosphamide 100mg/m2 PO D1 – 14, Methotrexate
40mg/m2 IV D1 & 8, and 5 Fluorouracil 600mg/m2 IV D1 & 8 every 28
days for 6 cycles OR
• TAC – Docetaxel 75mg/m2 D1 IV, Doxorubicin 50mg/m2 IV D1, and
Cyclophosphamide 500 mg/m2 01 IV every 21 days for 6 cycles.
234
2.
Radiotherapy - usual dose in the curative setting is 2Gy per fraction to
50Gy with a boost of 2Gy per fraction to 12 - 16Gy. Radiotherapy can
also be used in the treatment of painful local bone metastasis, spinal
cord compression, brain metastasis and for local disease on the chest
wall etc.
8.4. CERVICAL CANCER
Description
This is a cancer of the cervix.
Clinical features
Symptoms and Signs
• Irregular PV bleeding
• Per vaginal discharge iii) Lower abdominal pain
• Backache
• Dyspareunia
• Nodule, ulcer, or fungating growth
Complications
• Anaemia
• Sciatic pain
• Backache
• Incontinence of urine or faeces
• Sepsis
• Uraemia
Diagnosis
1. History and physical examination
2. Cervical biopsy must be taken
3. CXR
4. FBC, U/Es, LFTs HIV and CD4 count
5. IVP
6. Abdominal Ultrasound (to rule out hydronephrosis and metastases in
the abdomen)
7. EUA, cystoscopy and proctoscopy optional
Treatment
235
This depends on the stage of the cancer
i. Surgery for stage IB1 or less. Note surgery should not be done in cases
with stage IB2 and above.
ii. Chemoradiation for stages IB2 - IVA
There is no role of chemotherapy alone in stage IB2
- IVA and therefore all these patients need to be referred to the Cancer
Diseases Hospital via UTH Radiotherapy - 2Gy per fraction to 46 - 50Gy of
External beam radiation therapy (EBRT) with Brachytherapy to a total of 75
- 85GY to point A. chemotherapy is given concurrently with the radiation
using Cisplatinum 80mg/m2 IV 3 weekly.
8.5. OVARIAN CANCER
Description
These are malignancies of the ovaries.
Classification
1. Epithelial Ovarian Cancer
2. Germ Cell Ovarian Cancers
3. Stromal Tumours
The most common of these are the epithelial ovarian cancers. The prognosis
depends on the stage at diagnosis and the histologic type.
Clinical Features
70 - 800/o are diagnosed at an advanced stage. Early-stage disease is difficult
to diagnose due to lack of specific signs and symptoms. Have a high index of
suspicion. Symptoms and signs: pelvic mass, lower abdominal pain,
abdominal distension, and Ascites.
Diagnosis
•
•
•
•
•
History and physical examination
Ultrasound of abdomen and pelvis CT scan abdomen and pelvis
CXR
FBC, U/Es, CA 12S
Definitive diagnosis confirmed by Histology
Treatment
236
1. Primary treatment is surgery maximal de-bulking aiming for less than
2cm of residual disease.
2. Adjuvant Treatments: This requires a thorough pathologic staging and
selection of adjuvant therapies is dependent on stage and grade of cancer
(For staging readers are referred to the latest FIGO and AJCC cancer
staging manual).
i) Early Stage low risk - stage IA and 1B grade 1 &2 No further
treatment after maximal surgery
ii) Early Stage High Risk - Stage IA and 1 B with grade 3 or clear cell
histology, stage IC and Stage II disease; these require Carboplatin
AUC 5 - 7 IV and Paclitaxel 175mg/m2 IV 21-day cycles for 3 - 6
cycles,
OR
Cisplatinum 75mg/m2 IV and Paclitaxel 735mg/m2 IV infusion over
24 hrs (Neurotoxic)
OR
Carboplatinum and Cyclophosphamide 750mg/m2 IV.
iii) Advanced Disease stage
As for early-stage but for 6 - 8 cycles. Interval de-bulking as indicated.
237
8.6. ENDOMETRIAL CANCER
Description
These are cancers that arise from the Uterus.
Classification
1. Epithelial – Adenocarcinoma, adenosquamous, papillary serous
2. Stromal tumours – Sarcomas of the uterus
Prognosis and adjuvant treatment are dependent on the grade, histology and
stage of cancer.
Clinical Features
• Postmenopausal bleeding
Diagnosis
• History and physical examination
• Endometrial biopsy
• CXR
• Abdominal and pelvic ultrasound
• FBC, U/Es, LFTs
Treatment
1.Primary treatment is surgery TAH and BSO plus or minus pelvic
lymphadenectomy. For patients who refuse surgery or are medically
inoperable curative radiotherapy is indicated.
2.Adjuvant treatments depend on stage, grade, and histology; Radiotherapy
with either vaginal brachytherapy alone or in combination with external
beam radiation therapy at 2Gy to 50Gy.
3.Systemic therapy includes:
d) Hormonal Therapies with Medroxyprogesterone acetate 400 – 800mg
PO twice weekly, Tamoxifen 20mg daily
e) Chemotherapy TAP i.e. Cisplatinum 50mg/m2 IV, Adriamycin
45mg/m2 iv D1 followed by Paclitaxel 160mg/m2 repeat every 21 days
OR carboplatin and Paclitaxel as for Ovarian cancer.
8.7. PROSTATE CANCER
Description
238
This is a malignancy of the prostate gland. The patient is usually elderly but
the condition may occur in young men.
Clinical features
i)
Prostatism - hesitancy, poor stream, frequency in passing urine,
dribbling of urine, and urinary retention
ii)
Bone pain due to metastases
Diagnosis
i)
History and physical examination including a DRE
ii)
PSA any value above 4mg/mL requires core biopsy
iii)
Core biopsy i.e. 6 cores from each side and well labelled. The
pathologist must give a Gleason Score
iv)
FBC, U/Es and creatinine, CMP, LOH, LFTs, and ESR
v)
CXR
vi)
Trans-rectal ultrasound morphology
vii)
Bone Scan
viii)
Outflow obstruction tests; bladder ultrasound, urine flow rates,
Intra Venous Urogram (IVU)
Treatment
Depends on prognostic grouping, i.e.
• Favourable risk:
the four options of treatment in this group are Curative Radiotherapy,
Brachytherapy, Radical Prostatectomy, and Active Surveillance. No
adjuvant Androgen deprivation.
• Intermediate risk:
Curative Radiotherapy with neoadjuvant androgen deprivation for 3
months prior to radiotherapy. Some patients may require transurethral
resection of the prostate to relieve symptoms of urinary retention
• High risk but still organ-confined:
Radiotherapy to whole pelvis plus adjuvant androgen deprivation for a
period of 2 - 3 years. Some patients may require transurethral resection
of the prostate.
• Metastatic disease, options include:
i) Surgical castration (Bilateral Subcapsular Orchidectorny) and some
patients may require transurethral resection of the prostate
ii) Medical castration with LHRH agonists Goseriline plus an
antiandrogen is given two weeks before Goseriline is commenced.
239
iii) Antiandrogens: Cyproterone acetate 50 – 100mg TDS PO daily for 2 3 years.
iv) Chemotherapy with Docetaxel 75mg/ m2 IV repeat 21 days for 6 cycles
with or without estramustine or prednisolone, in those patients who
have failed after adequate androgen deprivation therapy.
Radiotherapy to treat painful bony metastasis including spinal cord
compression.
8.8. TESTICULAR TUMOURS
Description
These are malignant growths that arise from the testis. It is a common
malignancy in males aged between 15-34 years.
Classification
i)
Seminomas
ii)
Non-seminomas
Clinical Features
Testicular mass, that is either painful
Diagnosis
• History and physical examination
• Testicular ultrasound
• HCG, Fetoprotein, LOH
• FBC, U/E's, LFT's,
• CXR
Treatment
High Inguinal orchidectomy
Further treatment depends on the stage and histological type
Seminomas
Stage I disease: after surgery options include:
• Radiotherapy 2Gy to 20Gy total to paraaortic area
• Single agent, single dose Carbop latin dose in mg = 5 - 7 AUC (see
formula) or 400 mg/m2 IV
240
• Active surveillance (only in expert hands)
Stage II: Surgery followed by 2 - 3 cycles of BEP i.e.
• Bleomycin 30 units IV D1, 8 & 15
• Etoposide 100 mg/m2 D1 -5 IV,
• Cisplatin 20mg/m2 D1 - 5 IV every 21 days.
Stage III: Surgery followed by 4 cycles BEP as above
Non-Seminomas
Stage I: Surgery followed by BEP chemotherapy 2 -4 cycles every 21 days
Stage II and III: Surgery followed by BEP chemotherapy 4 cycles every 21
days.
241
8.9. VULVAL CANCER
Description
These are cancers that arise from the vulva and are mostly Squamous Cell
Carcinomas
Clinical Features
Pruritus, waterly discharge, bleeding, mass, pain and ulceration.
Diagnosis
•
History and physical examination
•
Biopsy including pap smear and colposcopy
•
CXR
•
FBC, U/ Es and LFTs
•
HIV and CD4 count
Treatment
All patients must be seen and assessed at the combined Gynaecology and
Oncology meeting to plan treatment
1. Primary treatment
a) surgery with 1cm margin of resection of the vulval lesion and inguinal
lymphadenectomy
b) Definitive chemoradiation for inoperable patients, refused or medically
inoperable patients. Radiotherapy 1.8Gy per fraction to 66-70Gy concurrent
with chemotherapy
2. Adjuvant treatment
a) Post-operative chemoradiation is indicated for patients with the following;
positive or close <8mm, 2 or more positive lymph nodes. Radiotherapy
1.8Gy per fraction to a total of 60-65Gy
b) Preoperative chemoradiation is indicated for
patients with central disease within 1cm of vital structures, fixed bulky
positive or ulcerating nodes or inoperable primaries to downsize them for
operability. Radiotherapy 50Gy split course with surgical assessment after
30Gy followed with 20Gy boost concurrent with chemotherapy
Regimens
1. Chemotherapy ONLY in comb ination with Radiation therapy
242
a) 5-Fluorouracil 400mg/m2 IV D1 - 4 and D28 -32 plus Cisplatin 25mg/m2
IV D1 - 4 and D28 - 32
b) Radiotherapy
243
8.10. PENILE CANCER
Description
This is cancer that arises from the penis.
Classification
Most of these are squamous cell carcinomas
Clinical Features
Penile nodule, mass, or ulcer which is non-healing.
Diagnosis
• History and physical examination
• Biopsy of ulcer or mass
• CXR
• FBC, U/Es
• HIV and CD4 count
Treatment
1. Surgery: in the form of circumcision, excision, partial or total
penectomy followed by bilateral inguinal node dissection in clinically
involved nodes.
2.
Radiotherapy: curative radiotherapy is used in young patients who still
want to preserve penile function.
3.
Chemotherapy is given concurrent with radiotherapy using Cisplatin
25mg/m2 D1 - 4 IV and D28 - 32 and 5-Fluorouracil 400 mg/m2 D1 4 and D28 - 32 IV.
8.11. NON-MELANOMA SKIN CANCER
8.11.1. Squamous Cell Carcinoma of the skin
Description
This is a cancer of the squamous cells of the skin.
Symptoms and signs
•
Plaque or nodule on the skin
244
• Non-healing ulcer
Diagnosis
History and physical examination
• Biopsy
• Imaging studies as indicated especially for extensive disease
Treatment
Surgery: Excision with adequate margins Radiotherapy
with or without concurrent chemotherapy.
8.11.2. Basal cell carcinoma
Description
This is cancer derived from the epidermal basal cell layer. It is more common
in elderly people and Caucasians.
Symptoms and Signs
• Nodule
• Skin thickening
• Ulcer with rolled-up margins
Diagnosis
• History and physical examination
• Biopsy
Treatment
i)
Early removal by curettage
ii)
Cryotherapy
iii)
Surgery: excision with adequate margins
iv)
Radiotherapy.
For patients in whom surgery would result in poor cosmesis and function,
radiotherapy is the treatment of choice.
245
8.11.3. Melanoma
Description
This is a neoplasm arising from melanocytes. It is the
commonest of fatal skin cancer. Some melanomas arise in pre-existing
moles.
Symptoms and Signs
i)
Rapid enlargement of a pigmented lesion
ii)
Bleeding
iii)
Increasing variegated pigmentation
iv)
Ulceration
v)
Persistent itching
vi)
Small satellite lesions around the principal lesion
vii)
Local regional lymph node involvement
ABCD are suspicious symptoms of lesions that are progressing to
melanomas
Asymmetry
• Irregular borders
• Colour variegation
• Diameter greater than 6mm
Diagnosis
• History and physical examination
• Excisional biopsy or full-thickness wedge/ punch biopsy
• CXR (stage 1B and above)
• FBC, U/Es, LFTs, LDH
• CT Scan depending on the site of primary disease
Treatment
Prompt excision with wide margins with local regional lymph node
dissection
Metastatic disease
• Radiotherapy for palliation
• Chemotherapy with either single agent Darcabazine 200mg/m2 D1 -5 or
750 - 800mg/m2 IV D1 every 3 weeks
246
8.11.4.
Kaposi's sarcoma
Description
This is cancer arising from capillary endothelial cells associated with HHV8.
Classification
In Zambia we commonly see
1. Endemic type
2. Epidemic type of KS. This is associated with HIV infection
Clinical features
Signs and Symptoms
• Purple (dark) papules, nodules, patches and plaques on the skin and
mucosa
• Lymphadenopathy
• Woody oedema of the legs
• Visceral involvement
Diagnosis
• History and physical examination
• Biopsy of Lesion (skin, mucosal or lymph nodes)
• HIV and CD4
• FBC, U/Es, LFTs
• CXR
Treatment
Depends on the type of the KS
1. Endemic KS: Local radiotherapy
2. Epidemic KS: Start antiretroviral therapy.
Chemotherapy
Radiation therapy for localized disease
Chemotherapy regimens
ABV: Adriamycin (Doxorubicin) 20mg/m2 IV D1, Bleomycin 15 Units IV
D1, Vinblastine 6mg/m2 IV D1
247
Repeat cycle every 14 - 21 days tapered to the best response (response is
therefore individualized).
Note: Do not exceed 450mg/ m2 Doxorubicin (Adriamycin) total/absolute
dose. Use BV only after 6 cycles of ABV.
Liposomal Doxorubicin 20mg/m2 IV every 14 days or Danaurubicin
40mg/m2 IV every 14 days to the best response.
Paclitaxel 100mg/m2 every 14 days OR 135mg/m2 every 21 days to the best
response.
8.12. OESOPHAGEAL CARCINOMA
Description
This is a malignancy that arises from the oesophagus.
Classification
The majority are Squamous cell carcinomas. Adenocarcinomas arise
commonly from the lower third
(gastro-oesophageal junction).
Symptoms and Signs
• Progressive dysphagia
• Pain
• Odynophagia (painful swallowing)
• Weight loss
• Regurgitation
• Vomiting
Diagnosis
• History and physical examination
• Barium swallow
• Oesophagoscopy and biopsy
• CXR
• FBC, U/Es, LFTs
• For lesions less than 5cm, do CT scan, chest and Abdominal ultrasound
• Endoscopic ultrasound
248
Treatment
For lesions less than 5cm
• Surgery – Oesophagectomy for primarily operable tumours
• Preoperative chemo-radiation followed by surgery for those requiring
downsizing
For lesions 6 – 7cm
• Curative chemo-radiation
Chemotherapy
• Cisplatin 40mg/m2 IV weekly concurrent with radiotherapy at 1.8Gy per
fraction to 50.4Gy
OR
5-Fluorouracil 400mg/m2 IV D1-4 with Cisplatin 75mg/ m2 IV D1 repeated
every 21 days concurrent with radiation therapy
Lesions more than 7cm and all patients who have lost more than 10% of their
body weight will require
Palliative treatments
Surgery i.e. dilatation, stenting, bypass
Radiation therapy with external beam alone, brachytherapy alone
or a combination of these
8.13.
COLORECTAL CARCINOMA
Description
Cancer of the large bowel.
Symptoms and Signs
•
Rectal bleeding
•
Mucoid rectal discharge
•
Alternating constipation with diarrhoea Intestinal obstruction
•
Anaemia Weight loss
Diagnosis
•
History and physical examination including a digital rectal
examination
249
•
•
•
•
•
•
Double-contrast barium enema
Proctosigmoidoscopy and colonoscopy with BIOPSY
FBC, u/Es, LFTs, CEA
CXR
Ultrasound of abdomen and pelvis Transrectal ultrasound
CT Scan abdomen and pelvis
Treatment
The mainstay of treatment is surgery.
Adjuvant treatment for colon cancer
• Stage I and II no further treatment after surgery but require follow up
with a yearly colonoscopy
• Stage III and IV will require adjuvant chemotherapy
Adjuvant treatment for rectal carcinoma
• Preoperative short-course radiotherapy: 5Gy daily for 5 days followed by
surgery one week later.
• Preoperative long course chemo-radiation
• Post-operative chemo-radiation
Chemotherapy regimen:
FL: 5-Fluorouracil 425mg/m2 D1 – 5 IV; Leucovorin 20mg/m2 D1 – 5 IV
30 minutes before 5-FU
Repeat every 28 days for 6 cycles
OR
FOLFOX
• 5-Fluorouracil as above
• Leucovorin as above
• Oxaliplatin 85mg/m2 D1 only IV
8.14.
GASTRIC CANCER
Description
This is a cancer of the stomach.
250
Classification
Most are adenocarcinomas.
Symptoms and Signs
Initially, symptoms are vague and non-specific.
• Dysphagia
• Post-prandial fullness
• Heartburn
• Indigestion
• Loss of appetite
• Weight loss
• Abdominal discomfort and fullness
• Haematemesis and melaena
• Anaemia
Diagnosis
• History and physical examination
• Endoscopy with biopsy
• FBC, U&Es, LFTs, CEA
• Barium meal
• CXR
• Abdominal ultrasound CT scan of the abdomen
• Endoscopic ultrasound
Treatment
• Surgery - Is the primary treatment. Subtotal or total gastrectomy with
adequate lymphadenectomy and negative margins.
• Radiotherapy
- Adjuvant Chemoradiation for stage 1B and above
- Definitive chemoradiotherapy for medically unfit or unresectable patients
- Palliative radiotherapy
• Chemotherapy
- Leucovorin 20 mg/m2 IV bolus, 5-Flourouracil 425mg/m2 IV bolus D7 D5 (cycle 7, 4,5)
- Leucovorin 20mg/m2 IV bolus, 5-Flourouracil 400mg/m2 IV bolus first
4 and last 3 days of radiotherapy (cycle 2 & 3)
- Metastatic cancer: - Leucovorin 20mg/m2 IV bolus, 5-Flourouracil
425mg/m2 IV bolus D1-D5 28-daycycle, 6 cycles.
251
8.15. PANCREATIC CANCER
Description
This is a cancer of the pancreas.
Classification
Adenocarcinomas
Symptoms and Signs
• Upper abdominal pain
• Vomiting
• Obstructive jaundice
• Pruritis
• Weight loss
• Symptoms of diabetes mellitus
• Migratory thrombophlebitis
• Upper abdominal mass
• Palpable gall bladder
Diagnosis
• History and physical examination
• Endoscopic ultrasound and/ERCP/ biopsy
• FBC, LFTs, U & Es, CEA, blood glucose
• CXR
• CT scan
Treatment
1.
Surgery: Definitive - Mainstay of treatment (Whipple's procedure)
2.
Palliative surgery for advanced cases - Endoscopic or Percutaneous
biliary stent, Open biliary enteric bypass.
3.
Radiotherapy
Post-operative 5-FU-based chemoradiation (45-54Gy at 7.8-2Gy/day)
followed by systemic Gemcitabine
Localised unresectable disease and good performance status - Concurrent 5FU based chemoradiation (50-60Gy at 7 .8-2Gy /day)
252
Palliation of pain and metastases.
Chemotherapy
- With Chemoradiation FU-500mg/m2 IV bolus on first and last 3 days of
radiotherapy
- Gemcitabine 1000mg/m2 over 30minutes IV D1,
8 & 7 every 28 days for 6 cycles as adjuvant therapy and locally unresectable
or metastatic disease.
8.16.
ANAL CANCER
Description
This is a cancer of the anal canal.
Classification
• Squamous
• Cloacogenic (transitional)
• Adenocarcinoma
• Others – Paget’s disease, basal cell, melanoma, lymphoma
Symptoms and signs
• Bleeding
• Anal pain
• Pruritis
• Palpable mass
• Change in bowel habit
• Chronic anal condition
• Haemorrhoids, fistula, fissure
Diagnosis
• History and physical examination including DRE, gynaecologic exam in
women
• EUA, Proctoscopy, Biopsy of the primary tumour
• FNA/biopsy of clinically suspicious inguinal nodes
• CXR
• Abdominal pelvic CT scan
• Ultrasound abdomen and pelvis if unable to do a CT scan
• FBC, U&Es, LFTs, HIV, CD4
253
Treatment
Surgery
• Wide local excision – Only in tumours <2cm which is welldifferentiated, and preservation of anal function assured
• Abdominal perineal resection – is reserved only for salvage of patients
who have failed chemoradiotherapy
Combined modality therapy
• Chemoradiation is the standard primary treatment option with doses of
45-60Gy
• 5-Fluorouracil 400mg/m2 Day1-4 and Day 22-25 of radiotherapy
• Mitomycin-C 10mg/m2 Day 1 only.
Mitomycin may be substituted by Cisplatin especially in HIV positive
patients.
8.17. ASTROCYTOMAS
Description
These are glial tumours (astrocytomas and oligodendrogliomas) that arise
from supportive tissues in the CNS and represent over 400 out of all CNS
tumours in adults. In childhood, astrocytomas predominate.
Classification
•
Low-grade astrocytomas include WHO grade I (fibrillary, pilocytic)
and II (astrocytoma)
•
High-grade astrocytomas include WHO Grade III (anaplastic) and IV
(glioblastoma multiforme)
Symptoms and signs
•
Headache (usually persistent)
•
Nausea, vomiting
•
Poor balance and coordination
•
Seizures
•
Hemi- or para-paresis
•
Visual disturbances
Diagnosis
•
History and physical + neurological examination
254
•
•
•
Skull X-ray
Brain CT or MRI scan
Radionuclide brain scan
Treatment
The mainstay of treatment is complete surgical resection where possible for
both low or high grade
•
Low-grade astrocytomas
Complete resection followed by observation
In incomplete resection observation or adjuvant chemotherapy
and/or radiation therapy is considered
•
High-grade astrocytomas (anaplastic or glioblastoma multiforme)
Complete surgical resection followed by radiotherapy alone or
concurrent with Temozolomide
Chemotherapy:
• Single-agent regimens
- Carmustine (BCNU) 80 mg/m2 IV D1-3 every 6-8 weeks
- Lomustine (CCNU) 130 mg/m2 PO D1 every 6-8 weeks
• Combination chemotherapeutic regimens
1.PCV
Procarbazine 60mg/m2 PO D8-21
Lomustine 110 mg/m2 PO D1
Vincristine 1.4 mg/m2 IV D8 & D29
Repeat every 6-8 weeks (max 10 courses)
2.P E
Cisplatin 30 mg/m2 IV D 1-3
Etoposide 150 mg/m2 IV D 1-3
Repeat every 3 weeks 6-8 courses
• Radiotherapy using 3D conformal radiation therapy technique
Low-grade gliomas 1.8Gy per fraction to 50.4Gy
High-grade gliomas 1.8Gy per fraction to a total of 54 – 59.9Gy.
8.18. LUNG CANCER
Description
This is a malignancy that arises from lung parenchyma.
Classification
255
Small Cell Lung Cancer (SCLC)
Non-Small Cell Lung Cancer (NSCLC) this includes squamous cell,
adenocarcinoma and large cell carcinoma.
Symptoms and signs
• Cough
• Bloodstained sputum
• Breathlessness
• Chest pain Difficulty breathing
• Weight loss
• Horse voice
• Unresolving pneumonia
• Paraneoplastic syndromes
1. SIADH secretion
2. Hypercalcaemia
3. Myopathy
4. Cerebellar degeneration
5. Myasthenic syndrome
Diagnosis
• History and physical examination
• CXR
• Histology
1.Sputum
2.Lung Biopsy FNAB or open lung biopsy
3.Pleural cytology or pleural biopsy
4.Lymph node biopsy via a Mediastinoscopy or mediastinotomy
• FBC, U/Es LFT s LOH, CMP
• CT chest and upper abdomen
• PET scan
Treatment
• SCLC
1.
Limited Stage disease: - concurrent chemoradiation with
Cisplatinum and Etoposide and Radiation therapy at 1.SGy BO to 45Gy. This
is followed by prophylactic cranial irradiation for complete responders
256
2.
Extensive Stage disease: chemotherapy with Cisplatinum and
Etoposide followed with consolidation radiotherapy for patients with a neartotal or partial response.
•
NSCLC
The treatment depends on the stage
1.
Stage I, II and IIIA:- Surgery is mandatory followed with 4 cycles
of adjuvant chemotherapy with
Cisplatin + Etoposide or Carboplatin + Vinorelbine, or Cisplatin +
Gemcitabine. In completely resected NSCLC radiation therapy to 60Gy is
reserved for those with positive lymph nodes or resection margins.
2.
Locally advanced is treated with chemoradiation to 66Gy
concurrent with Cisplatinum based chemotherapy
3.
Metastatic disease is treated with chemotherapy and radiotherapy
is used in this situation for palliation.
8.19. NASOPHARYNGEAL CARCINOMA
Description
This is a carcinoma that arises from the nasopharynx commonly the Iossa of
resenmuller.
Classification
•
Keratinising squamous cell carcinoma WHO type I
•
Non-keratinizing squamous cell carcinoma WHO type II.
•
Undifferentiated squamous carcinoma or lymphoepithelial carcinoma
WHO type III.
Symptoms and signs
•
Nasal voice
•
Nasal congestion and obstruction
•
Nasal bleeding
•
Neck swellings/lymphadenopathy
•
Cranial nerve palsies
•
Other CNS signs
•
Bone pain and/or tenderness
Diagnosis
257
•
•
•
•
•
History and physical examination
CXR
FBC, U/Es, LFTs
CT Scan whole brain and base of the skull to the clavicle
Biopsy of nasopharynx
Treatment
The mainstay of treatment of NPC is radiotherapy.
Stage I & II:
Curative radiation therapy to 70Gy at 1.8 – 2GY per fraction
Stage III:
Chemoradiation to 70Gy with Cisplatinum 75–100mg/kg IV 3 weekly
starting with day 1 of radiation treatment and currently this is followed with
4 cycles of Cisplatinum and 5-Fluorouracil
8.20. OTHER HEAD AND NECK CANCER
Sites
•
Larynx
•
Oral cavity
•
Oropharynx
•
Nasal cavity and paranasal sinuses
•
Salivary gland tumours
All these sites have unique symptoms and signs
Treatment
Depends on the stage
Stage I & II:
Surgery or curative radiation therapy produce equivalent results but differ in
the side effect profile.
Stage III:
has three options of treatment
4. Surgery followed with postoperative radiation therapy plus or minus
chemotherapy
5. Curative chemoradiation for organ sparing
6. Radical radiotherapy for medically challenged patients who cannot
stand chemotherapy
258
8.21. THYROID CANCER
Description
These are malignancies that arise from the thyroid gland
Classification
There are four categories based on the WHO classification.
Two differentiated Thyroid Cancer
Papillary Adenocarcinoma
follicular Adenocarcinoma
• Medullary thyroid carcinoma
• Anaplastic thyroid carcinoma
• Malignant lymphomas of the thyroid are not uncommon
Symptoms and signs
• Thyroid nodule – found incidentally or during routine physical
examination
• Lump in the neck
• hoarseness of voice if recurrent laryngeal nerve involved or extension to
the larynx,
• Dysphagia if an oesophageal extension is present.
• Neck nodes
• Haemoptysis
• Cough
• Chest pain
• Bone pain
• Diarrhoea due to calcitonin, serotonin or prostaglandin production in
those with MTC.
Diagnosis
• History and examination
• ENT exam
• Ultrasound of the neck FNAB is recommended at this stage
• CXR
• FBC, CMP, U/E’s and LFT’s
• Preoperatively
– Routine use of CT scan, MRI and PET scan is not recommended
– Thyroglobulin level not recommended
•
Postoperatively
259
– All patients with papillary and follicular cell carcinoma must have an
initial 131-Iodine diagnostic scan within 6 weeks post-surgery
– Ultrasound of the neck with Tg levels
– CT scan with contrast is contraindicated
– Non-contrast CT chest can detect pulmonary metastasis
– PET scan is useful in patients with:
– increased Tg levels and a negative 131-Iodine uptake scan
– MRI - useful post-op in all forms of thyroid cancer to detect local
recurrence
Treatment
Surgery is the definitive treatment for all the histological types mentioned
previously. This must be a near or total resection with a central neck
dissection done plus posterior lateral neck dissection if these nodes are
involved. For OTC surgery is followed by radioactive iodine therapy in
selected cases. ATC require adjuvant radiotherapy and/or chemotherapy after
surgery. MTC a thyroidectomy is followed by genetic testing of the
individual and family members.
Radio-active Iodine 131 Therapy:
this is indicated in all OTC patients with a positive RAI uptake scan at 6
weeks post-operatively, in which case 100 - 150mCi is given orally. This
achieves 85 - 95% complete ablation of residual thyroid tissue. A repeat
whole-body scan is done at 5 - 10 days post-131-Iodine therapy. Start thyroid
replacement and at 3 months do TSH and Thyroglobulin and at 6 months
repeat 131-Iodine uptake scan. This is repeated every 6 months until all
thyroid tissue is ablated including metastatic areas.
Radiation therapy:
is used for inoperable tumours, and in palliation of symptomatic metastatic
areas.
Chemotherapy:
the preferred agent is Doxorubicin and is indicated in ATC only
postoperatively.
8.22. PAEDIATRIC CANCER
260
8.22.1. Medulloblastoma
Description
Medulloblastoma is a primitive cerebellar tumour of neuroectodermal
origin that is the most common posterior fossa malignant tumour in
children. It accounts for 20% of paediatric brain tumours.
Symptoms and Signs
• Headache
• Vomiting
• Convulsions
• Ataxia
• Cranial nerve palsies
• Coma and unconsciousness
• BP and pulse
Diagnosis
• History and physical examination
• CSF cytology
• MRI or CT scan of the brain and whole spine
• FBC, U/Es
• Audiometry
• Histological confirmation is done after craniotomy and complete
resection of the tumour
Treatment
Depends on the risk category
• Average Risk: children older than 3 years, no metastasis, near to total
resection, with less than 1.5cm2 residual disease on early postoperative
imaging (24-48hrs)
• High Risk: overt metastatic disease based on CSF cytology or imaging >
1.5cm2 residual disease, and all children < 3 years of age.
1. Surgery:
Maximal judicial surgical resection is the most important step. However, the
aggressiveness of surgery is sometimes associated with the posterior Iossa
syndrome in up to 150/o of children post-op. (difficulty swallowing, truncal
ataxia, mutism and less often respiratory failure)
261
2.
Radiation Therapy
• Average Risk Medulloblastoma:
The standard of care for average-risk medulloblastoma is either Cranial
Spinal Irradiation (CSI) to 23.4Gy with platinum-based chemotherapy, OR
CSI to 35 Gy without chemotherapy with a boost in both situations of the
posterior Iossa to a total dose of 54 - SSG y in both situations
•
High-Risk Medulloblastoma:
Post-operative irradiation is given first followed by chemotherapy as a
preferred sequence.
However pre-irradiation chemotherapy is sometimes utilised in some centres
with a risk of disease progression.
Chemotherapy regimens
•
Vincristine 1.5mg/m2 D1 weekly for 3 consecutive weeks
•
Lomustine (CCNU) 75mg/m2 orally D1, Cisplatin 75mg/m2 IV
D1
•
Repeat every 6 weeks for 8 cycles.
8.22.2. Retinoblastoma
Description
A malignant tumour of the embryonic neural retina that may arise from single
or multiple foci in one or both eyes
Clinical features
Symptoms
i)
White pupillary reflex
ii)
Leucokoria
iii)
Red painful eye
iv)
Strabismus
v)
Eye tumour
Signs
i)
Creamy-pink mass projecting into vitreous
ii)
A white avascular tumour
iii)
iv)
Retinal detachment
Vitreous haemorrhage
262
v)
Clouding of the anterior chamber
Complications
• Loss of vision
• Local Pain
• CNS disease
• Anaemia
Diagnosis
• History and Clinical Examination findings
• Investigations for Staging of Retinoblastoma
I. The intraocular extent of disease
Indirect ophthalmoscopy
Ultrasonography of globe
II. The orbital extent of disease
A. Plain X-ray of the optic foramen, orbit, and skull
B. CT scan of the orbit
III. Metastatic evaluation
A. LP: CSF for cytology
B. FBC
C. LFTs include ferritin and NSE
D. BM aspiration for histology and cytogenetics; BM biopsy
E. Abdominal US (Liver/Spleen)
F. CT of brain, head and Abdomen
G. Bone Scan
H. Biopsy of extraocular masses
I. Globe and optic nerve stump histopathology (if enucleation is
done)
Added investigations to include ECG and as patient’s condition dictates.
Reese-Ellsworth Intraocular staging:
Group I. Very favourable
A. Solitary tumour, less than 4 disc diameters in size at or behind the equator
B. Multiple tumours, none over 4 disc diameters in size at or behind the
equator
Group II. Favourable
A. Solitary tumour, 4-10 disc diameters in size at or behind the equator
263
B. Multiple tumours, 4-10 disc diameters in size behind the equator
Group III. Doubtful
A. Any lesion anterior to the equator
B. Solitary tumours larger than 10 disc diameters in size behind the equator
Group IV. Unfavourable
A. Multiple tumours larger than 10 disc diameters
B. Any lesion extending anterior to the oraserrata
Group V. Very unfavourable
A. Massive tumours involving more than one-half the retina
B. Vitreous seeding
*Staging for the probability of retaining useful vision rather than survival.
Grabowski-Abramson Clinicopathologic Staging of Retinoblastoma
Stage Description
I. Intraocular disease
a. Retinal tumour, single or multiple
b. Extension to lamina cribrosa
c. Uveal extension
II. Orbital disease
a. Orbital tumour
1. Scattered episcleral cells
2. Tumour mass
b. Optic nerve
1. Distal nerve; the line of resection and meninges clear
2.
Tumour at the line of resection or in meninges
III. Intracranial metastasis
a. Positive CSF alone
b. A mass lesion in CNS
IV. Haematogenous metastasis
a. Positive BM alone
b. Focal bone lesions with or without positive marrow
c. Other organ involvement
264
Treatment
Stage/extent of disease determines the choice of treatment modality.
Treatment modalities for the intraocular disease include:
1. External beam radiotherapy
2. Episcleral plaque therapy
3. Photocoagulation
4. Cryotherapy
5. Enucleation.
6. A combination of the above modalities
Treatment modalities of extraocular disease: Adjuvant chemotherapy
improves survival in patients with extraocular disease following enucleation.
Patients with overt CNS disease or with a high probability of meningeal
spread should receive intrathecal methotrexate and cytosine arabinoside, and
if possible cranial irradiation. Stage II, III and IV all require multimodality
therapy of Enucleation, Radiation and Chemotherapy (plus intrathecal
chemotherapy).
265
Medicine Stage II and III
Phase
Week
Medicine
Dose
0
Cyclophosphamide
Doxorubicin
Vincristine
40 mg/kg IV, Day 1
0.67 mg/kg IV, Days 1, 2, 3
0.05 mg/kg IV, Day 1
Cyclophosphamide
Doxorubicin
Vincristine
20 mg/kg IV, Day 1
0.67 mg/kg IV, Days 1, 2, 3
0.05 mg/kg IV, Day 1
24-57
(Repeat every 3rd week)
Cyclophosphamide
Vincristine
30 mg/kg IV, Day 1
0.05 mg/kg IV, Day 1
0, 1, 2, 3, 4, 5
Methotrexate
Cytarabine
IT
IT
3-21
(Repeat every 3rd week)
266
Medicines Stage IV
Phase
Week
Medicine
Dose
0
Cyclophosphamide
Doxorubicin
Vincristine
40 mg/kg IV, Day 1
0.67 mg/kg IV, Days 1, 2, 3
0.05 mg/kg IV, Day 1
Cisplatin
Etoposide
3 mg/kg IV, Day 1
3.3 mg/kg IV, Days 1, 2, 3
Cyclophosphamide
Doxorubicin Vincristine
30 mg/kg IV, Day 1
0.67 mg/kg IV, Days 1, 2, 3
0.05 mg/kg IV, Day 1
3, 9, 15, 21
6, 12, 18, 24, 27, 30, 33
267
Phase
Week
Drug
Dose
36 – 105
(Repeat every 3rd week)
Cyclophosphamide
Vincristine
30 mg/kg IV, Day 1
0.05 mg/kg IV, Day 1
0, 1, 2, 4, 5, 6
Methotrexate
Cytarabine
IT
IT
268
8.22.3. Nephroblastoma (Wilms' Tumour)
Description
A primary malignant renal tumour of childhood that is derived from primitive
and may arise in one or both kidneys occurring with equal frequency in both
girls and boys and may be associated with congenital anomalies.
Clinical features
Signs and Symptoms
Commonly presents as a palpable mass in the abdomen. Other symptoms and
signs include any of the following:
• Hypertension
• Hematuria
• Obstipation
• Weight loss
• Dysuria Diarrhoea
Others: nausea, vomiting, abdominal pain, cardiac insufficiency, pleural
effusion, polycythemia, hydrocephalus
Wilms tumour may occur in association with congenital anomalies in some
patients.
The most frequent congenital anomalies are:
Congenital aniridia
Hemi-hypertrophy
Beck with-Wiedemann syndrome
Hyperplastic fetal visceromegaly involving the kidney, adrenal cortex,
pancreas, gonads and liver
Macroglossia, omphalocele, hemihypertrophy, microcephaly,
retardation, hypoglycemia and postnatal somatic gigantism
mental
Associated with an increased incidence of WT, adrenal carcinoma,
hepatoblastoma, and gonadoblastoma
• Genitourinary tract anomalies
Diagnosis
History and physical examination
Investigations
• FBC, U/E, LFT, Coagulation profile
269
•
•
•
•
•
ECG and echocardiogram
Abdominal Ultrasound
IVU
CXR
Abdominal and Chest CT scan
Staging
International Society for Paediatric Oncology (SIOP)
Nephroblastoma staging
Stage
I
I
I
Description
Tumour limited to the kidney, complete excision
tumour extending outside the kidney, complete excision
a) invasion beyond the capsule, perirenal/perihilar
b) invasion of the regional lymph nodes (hilar nodes and/or
periaortic nodes at the origin of the renal artery
c) invasion of the extrarenal vessels
d) invasion of ureter
Invasion beyond the capsule, incomplete excision
a) preoperative or perioperative biopsy
b) preoperative/perioperative rapture
c) peritoneal metastasis
d) invasion of paraaortic lymph nodes
III
e) incomplete excision Distant metastasis
Treatment
270
Pre-nephrectomy Therapy
Phase
Week
Drug
Dose
Pre OP
1, 2, 3, 4
Vincristine
1.5 mg/m2 IV,
Day 1
1, 3
Actinomycin D
0.015 mg/m2 IV,
Day 1, 2, 3
Post-operative Therapy
Stage I, Favourable histology: No therapy Stage I, Standard histology and
anaplastic WT Drugs
Actinomycin D Vincristine
Phase
Week
Drug
Dose
Post OP
1, 2, 3,
4,
10, 11,
17,
18
1, 10
Vincristine
1.5 mg/m2 IV,
Day 1
Actinomycin D
271
0.015 mg/m2 IV,
Day 1, 2, 3, 4, 5
Stage II Standard histology
Drugs
Actinomycin-D (Dactinomycin)
Vincristine
Doxorubicin
Radiation
Phase
Week
Drug
Dose
Post OP
1, 2, 3,
4, 5, 6,
7, 8
11, 12,
&
14, 15
17, 18,
&
20, 21
23, 24,
&
26, 27
Vincristine
1.5 mg/m2 IV,
Day 1
1, 11
Actinomycin
-D
0.015 mg/m2
IV,
Day 1, 2, 3, 4,
5
4, 8, 14
Doxorubici
n
50 mg/m2 IV,
Day 1
2–3
Radiation
Stage II and III anaplastic WT, I to III clear cell sarcoma
Drugs
Actinomycin-D
Vincristine
Doxorubicin
Radiation
272
Phase
Week
Drug
Dose
Post OP
1, 2, 3,
5, 7
10, 11,
12,
and 14,
15
17, 18,
19,
and 21,
22
24, 25,
26,
and 28,
29
31, 32,
33,
and 35,
36
Vincristine
1.5 mg/m2 IV,
Day 1
Actinomycin
D
0.030 mg/m2
IV,
Day 1
1, 10
Doxorubicin
50 mg/m2 IV,
Day 1
3, 12
Ifosfamide
3000 mg/m2
IV,
Day 1
5-8
Radiation
5, 14,
21,
28, 35
273
8.22.4
Rhabdomyosarcoma
Description
A malignant tumour of striated muscle that may occur in any anatomical
location of the body, but commonly occur in the head and neck region, genital
urinary tract and extremities.
Clinical features
Symptoms and Signs
Commonly presents as a mass with specific clinical manifestations varying
with the site of origin
Head and Neck
Neck
- xxxxxSoft tissue mass
- Hoarseness
- Difficulties swallowing
Orbit
- Conjunctival mass
- Proptosis
- Ocular palsies
Nasopharynx & Paranasal sinus
- Swelling
- Local pain
- Epistaxis
- Difficulties swallowing
- Sinusitis
- Unilateral nasal discharge
Genitourinary
- Vaginal bleeding
- Vaginal mass
- Dysuria
- Haematuria
- Urinary obstruction
- Painless paratesticular mass
Diagnosis
274
History and Clinical Examination findings
Investigations for Staging of Retinoblastoma
• Urinalysis
• FBC
• U/E
• LFTs
• Skeletal X-rays
• CT Scan
• Bone Scan
• BM aspiration and Biopsy
• Biopsy of the tumour
Other special examinations and investigations
• Head and Neck tumour
• Ear, nose
throat examination under anaesthesia
• Ophthalmologic examination
• LP and CSF cytology
• Abdominal Pelvic tumour
• Abdominal US
• Cystoscopy
Grouping
Group I. Definition
A.
Localized, completely resected, confined to the site of origin.
B.
Localized, completely resected, infiltrated beyond the site of origin.
Group II. A. Solitary tumour, 4-10 disc diameters in size at or behind the
equator.
B.
Regional disease, involved lymph nodes, completely resected.
C.
Regional disease, involved lymph nodes, completely resected with
microscopic residual.
Group III.A local or regional grossly visible disease after biopsy only.
B. Grossly visible disease after >50% resection of the primary tumour.
Group IV. Distant metastasis present at diagnosis
Staging
TNM staging system
275
Stages 1 to IV Treatment
Multiple modality approach that is dependent on stage combining surgery,
chemotherapy and radiation
276
9.
EYE DISEASES
9.1.
THE RED EYE
This is characterised with the reddening of the eye caused by:
With Pain
Without Pain
Iritis
Conjunctivitis
Corneal Foreign Body – Allergic
Acute Glaucoma – Viral epidemic Haemorrhagic
Chemical Conjunctivitis – Bacterial Conj. (Ophthalmia
neonatorum)
Corneal Ulcers
Penetrating and Perforating Eye Injuries
9.1.1. With Pain
9.1.1.1.
Iritis
Description
It is the inflammation of the Iris.
Clinical Features
Symptoms
• Deep-seated eye pain
• Decreased vision
• Redness of the eye
• Light intolerance
• Watery eye
Signs
• Pink ring of blood vessels around the cornea – ciliary flush
• Small white spots on the back of the cornea – keratic precipitates
• Iris may be stuck to the lens – posterior synechiae
Treatment
• Atropine 1% Eye ointment twice daily
• Betamethasone 1% eye drops, or
277
• Hydrocortisone 1% eye drops, or
• Dexamethasone 0.1% eye drops, or Prednisolone 1% eye drops 1-2 times
a day
9.1.1.2. Corneal Foreign Body
Description
This is the presence of a foreign body on the cornea.
Clinical Features
Symptoms
• Red eye
• Watering eye discharge
• Difficulty to keep the eye open
• Pain
• Distorted vision
Sign
Foreign object may be seen on the cornea
Treatment
• Apply a drop of 2% Lignocaine onto the affected eye
• Wipe away the foreign body with a wisp of sterile cotton wool on an
orange stick
• If the foreign body does not come out easily refer to the nearest eye clinic
where it may need surgical removal
(with a hypodermic needle)
• Chloramphenicol 0.5% eye drops 1 drop every 2 hours, then reduce the
frequency as the infection is controlled.
• Pad the eye for 24 hours
9.1.1.3. Acute Angle Closure Glaucoma
Description
This is an acute increase in the intraocular pressure brought about solely by
the closure of the anterior chamber angle by the peripheral iris.
Predisposing Factor
• Small long-sighted eye
• Anatomical shallow anterior chamber
278
Clinical features
Symptoms
• Impaired vision
• Red eye
• Severe Periocular pain
• Nausea
• Vomiting
• Severe headache
Signs
• Ciliary flush
• Very, very high Intraocular pressure (50 – 100mmHg)
• Hazy Cornea Bathroom window glass type of cornea
(mid dilated pupil)
• Bombe iris
• Flare
• Dilated Iris vessels
• Painful hard eye
Investigation
Tonometry with a Schiotz or Perkins tonometer will show very high
intraocular pressure
Treatment
The definitive treatment is surgical
Medicines
• Acetazolamide 500mg intravenously start, then
250mg 6 hourly
• Pilocarpine 4% 6 hourly
• Paracetamol 500 – 1gm orally 6 hourly
This is the initial treatment to relieve the angle closure
Definitive Treatment
Permanently keep the angle open surgically by:
(i)Peripheral laser iridotomy
(ii)Peripheral Iridectomy
(iii)The surgery must be done to both eyes as the predisposing condition
affects both eyes
Other Hyperosmotic agents
279
Because of their speed of action and effectiveness, hyperosmolar agents are
of great value during the acute crisis of acute glaucoma to reduce the
intraocular pressure.
•
Mannitol (1-2g/kg body wt of 20% solution in water, given over 30
– 40 minutes, (60 drops per minute as a slow intravenous infusion) until intraocular pressure has been satisfactorily reduced
•
Urea 1-2kg body wt of a 30% solution in 10% invert sugar
9.1.1.4. Chemical Conjunctivitis
Description
It is an inflammation of the eye caused by a chemical substance.
Common Chemicals
• Car battery acid
• Snake venom
• Fluid from plants
• Household cleaning chemicals
• Alkali chemicals are more damaging to the eye than acids
Clinical Features
Symptoms
• Pain
• Redness
• Watering
• Pus discharge if secondarily infected.
Emergency management
– Apply local anaesthetic – lignocaine 2% eye drops
– Wash the eye copiously with normal saline or tap water for about 30
minutes
Investigation
Fluorescein staining will reveal the area of conjunctival corneal chemical
erosion
Treatment
• Hydrocortisone 1% Eye Ointment. Apply 3-4 times daily
• Atropine eye drops 1% 2 times a day
280
• Tetracycline 1% eye ointment three times daily if infected
Note that the first-line drug of choice is Hydrocortisone.
Use Tetracycline as the second line, only if a steroid is not available.
Other Medicines Used in Chemical Burns
• Vitamin C (Sodium ascorbate) 10% drops and a daily oral dose of
ascorbic acid 1gm (assist in laying down of the corneal collagen)
• Collagenase inhibitors: L-cysteine and or Cenicillamine applied topically
helpful in preventing corneal perforation
• Artificial tears: Prevents the effects of corneal drought. SNO tears, or
Hypromelrose 0.3%
• Bandage soft contact lenses prevent the formation of adhesions between
eyelid and eyeball
• Sodium EDTA - Chelates calcium, a cofactor for the collagenase enzyme,
thereby rendering the enzyme unavailable for corneal melting.
Late Treatment
Division of adhesions between conjunctiva of the eye and eyelid. Place an
eye shell between the divided bands during ball synechiealisis
Conjunctiva grafting
Eyelid surgery to correct the deformity
Corneal grating after 6 - 12 months to allow for maximum resolution.
9.1.1.5.
Corneal Ulcers
Description
This is ulceration of the cornea.
Common causes
• Injuries
• Infections: Bacteria, Fungal, Viral
• Other causes
Clinical Features
Symptoms
•
•
•
•
Red eye
Severe pain
Difficult to open eye in light (photophobia)
Discharge, water or pus
281
• Disturbed vision
Signs
• Poor vision on Snellen testing a white spot of the eye may be seen
• On retinoscopy – irregular light refraction Investigation
• Fluorescein staining of the cornea, the wound stains green
• Corneal swab for microscopy, culture and sensitivity
Treatment
Depends on the cause
For all types of ulcers, prevent ocular pain with atropine
1% once daily in the affected eye
Infections
•
Bacteria corneal ulcers: use Tetracycline 1% eye ointment, or
Chloramphenicol 1% eye ointment 3-4 times a day
•
If not resolving within 2 weeks, then refer
9.1.1.6. Fungal Ulcers
Typically see main ulcer, with riders, and satellite ulcers around the main one.
(This is seen occasionally. It may not be seen at all)
Treatment
• Povidone Iodine, 2%, four times daily in the affected eye
• Natamycin, 5% eye suspension given hourly for 7 days
• Econazole, 1% suspension for topical use
• Miconazole, 10mg/ml given subconjunctival or intravitreal given as
10microgram per ml
• Amphotericin B 0.05-0.2% can be made from IV injection and instil every
5 minutes during the first hour and 30 - 60minutes until clinical picture
changes. (protect from light- use umber coloured bottle)
9.1.1.7. Viral ulcers, Herpes simplex
Typical characteristic - on Fluorescein 1% or 2% staining a dendritic corneal
ulcer (branching)
Treatment
• Acyclovir eye ointment (suspension) five times daily in the affected eye
for about 21 days.
282
Note: If this has a very high association with HIV/AIDS steroids are
contraindicated
9.1.1.8. Ophthalmia neonatorum
Presents 2 – 4 days postpartum
Clinical reactive
Hyperacute conjunctivitis with pus, with or without a
membrane‚
Severe swelling of both eyes
Treatment
•
Penicillin G 50,0000 IU in 2 divided closes for 7 days
– systemic
•
Penicillin eye drops 1 hourly both eyes – Topical.
9.1.1.9 Penetrating and Perforating Eye Injuries
Description
Penetrating wounds are injuries of the eyeball that result from a sharp object.
They typically have a wound of entry and a wound of exit. There may or may
not have a retained foreign body.
Perforating wounds are injuries of the eyeball that have only one wound of
entry, there also may have a retained foreign body.
Clinical Features
Symptoms
• History injury present
• Red eye
• Painful eye
• Soft eye
Signs
• The eye may be shrunken due to loss of volume
• There may be subconjunctival haemorrhage.
• Pigment discolouration of the conjunctiva in the area of the wound
283
• Foreign Body may be seen.
Investigation
• X-ray orbit – to rule out intraocular foreign body.
• Ocular ultrasound
• Cranial CT scan
Treatment
• Tetanus toxoid
• I.V antibiotic preferably Cefotaxime 1g stat Or
• Gentamycin 80m IV start
Refer to the nearest eye unit promptly.
9.1.2. Without Pain
The main cause of red-eye without pain is conjunctivitis of different types:
a) Infective
• Bacterial
• Viral
b) Allergic
c) Chemical
9.1.2.1. Bacterial Conjunctivitis
Description
This is a bacterial infection of the conjunctiva.
Clinical Features
Symptoms
• Ocular discomfort – gritty sensation in the eye
• Eye discharge (pus)
• Diffuse conjunctival redness
Signs
• Red conjunctiva with discharge
• Normal vision (clear cornea)
Investigation
Fluorescein staining is negative
284
Treatment
Tetracycline 1% eye ointment 3 – 6 times daily
Supportive
Good personal hygiene to prevent re-infection
Facial washing.
9.1.2.2. Viral Epidemic haemorrhagic conjunctivitis
Description
This is a viral infection of the conjunctiva and is associated with bleeding.
The condition is very infectious and difficult to treat. It is often seen in
families and epidemics.
Clinical Features
Symptoms
• Pain
• Watery discharge
• Ocular discomfort
• Photophobia
Signs
• Sub conjunctiva haemorrhage (severe redness).
• Tender cervical lymph nodes, preauricular, submental groups
• Swollen conjunctiva
• Water discharge
• Normal vision
Complication
• Secondary bacterial infection
Treatment
• Tetracycline 1% eye ointment 3 times daily for 7 days
Supportive
Patient hygiene – do not share face cloth Wash face and eyes
9.1.2.3 Allergic conjunctivitis
Description
285
Allergic inflammation of the conjunctiva. This condition is common but very
difficult to treat. A positive family history of the atopic disease may be present
Clinical Features
Symptoms
Itchy eyes
Signs
Ring of pale, fleshy, pink-grey tissue around the cornea
Follicles on the tarsal conjunctiva (cobblestone type)
Treatment
Hydrocortisone 1% eye drops 3-4 times a day
Sodium cromoglicate 2% eye drops 5 times daily
9.2.
TRACHOMA
Description
This is an infection of the eye caused by Chlamydia Trachomatis. It is a
disease of the underprivileged communities, with poor hygienic conditions.
The common fly is the major vector in the infection and re-infection cycle. It
is one of the leading causes of preventable blindness in the world.
Characterized by an acute inflammation which appears in the first decade of
life, slowly progressing until the disease becomes inactive during the 2nd
decade of life. Last sequelae may not appear for many years.
Stages
• Trachoma Follicular (TF): characterized by follicles on the upper lid
conjunctiva
• Trachoma intense (TI):, characterized by acute red tarsal conjunctiva
with obliteration of blood vessel • Trachoma Scaring (TS): Tarsal
conjunctiva starts showing lines of scaring
• Trachoma Trichiasis (TT): – upper eyelid turns in, because of extreme
scarring and shortening of lid conjunctiva causing corneal damage and
ulceration
• Ulcerated Cornea (CO): starts scaring forming corneal opacification
Clinical features
Symptoms
286
• None
• Red eyes
• Ocular discomfort
Signs
• Follicles on the tarsal conjunctiva
• Eyelid conjunctional scaring
• In-turning of eyelids (entropion)
• Eyelashes rubbing on the cornea (Trichiasis) heading to corneal
ulceration
• Corneal scars
Treatment
WHO recommends adopting the SAFE strategy in proven endemic areas
(after conducting the survey).
S Surgery for stage 5
A Mass Antibiotic treatment. A single dose of Azithromycin 500mg. In
children 10mg/kg/bd/wt as start dose .
F Face washing (provision of clean and safe water – a multi-disciplinary
approach where MOH partners with other line Ministries responsible for safe
water as well as some international NGOs that fund this expensive aspect of
Trachoma control.
E Environmental sanitation – It’s a public health aspect of management
9.3. LUMPS AND BUMPS ON AND AROUND THE
EYEBALL
These are lumps and bumps on ana around the eyeball and are divided into:
–
Benign
–
Malignant
Common ones
•
Stye – KS (Kaposi Sarcoma)
•
Chalazion (eyelid cyst)
–
Squamous cell carcinoma of the
•
Orbital dermoid cyst
–
conjunctiva
•
Pinguiculae Retinoblastoma
•
Pterygia.
287
9.3.1. Stye
Description
This is a small abscess caused by an acute staphylococcus infection of a lash
follicle
Clinical Features
Symptom
Painful lump on the lid margin
Sign
Tender inflamed nodule or lump on the lid margin
Treatment
• None – usually undergoes spontaneous resolution
• Hot compresses
• Removal of associated eyelash and drain the pus
• Tetracycline eye ointment may be applied to prevent eyeball infection.
9.3.2.Tarsal Cyst (Chalazion)
Description:
This is a cyst on the eyelid that results from blockage of the duct of tarsal
glands. It is usually formed away from the lid margin.
Treatment
Incision and curettage (I & C).
288
9.3.3.Orbital Dermoid Cyst
Description
These are round, localized nodules or lumps in the upper temporal or upper
nasal aspect of the orbit. They arise from a displacement of the epidermis to
a subcutaneous location.
Types
(a)Simple type – not associated with body defect, these are superficially
located
(b) Complicated – deeply seated, with deep intra-ocular extension. Present
later in life with a displacement of the eyeball
Investigation
• X-ray skull
• CT Scan to rule out an intraorbital extension
Treatment
Surgery, total excision.
9.3.4. Pinguicula
Description
This is a yellowish-white growth on the bulbar conjunctiva adjacent to the
nasal or temporal aspect of the limbus.
This type does not involve the cornea.
Treatment
• Leave alone, if asymptomatic
• If inflamed – red – Tetracycline 1% eye ointment 2 times a day for 7 days.
9.3.5. Pterygium
Description
These are conjunctival growths on the nasal or temporal conjunctiva that
enlarge and encroach on the cornea. May cause a skin-like band over the
cornea that may cover the pupil.
Clinical features
Symptom
May not cause any problem
289
May be discomfort of the eyeball if the pterygium is inflamed.
Sign
Redness of the conjunctiva growth that lies within the palpebral fissure.
Treatment
Local Excision in case of progression towards the visual axis.
Tetracycline 1% eye ointment if inflamed, post excision
290
9.3.6. Malignant
9.3.2.1. Kaposi Sarcoma of the Conjunctiva and Eyelid (See section on
Malignancies)
Description
These are cancers arising from capillary endothelial cells. In the eye, they
present clinically as a patchy or patches of elevated “haemorrhage” that do
not resolve with time. It may be the first manifestation of AIDS. It may
present on the conjunctiva or the eyelid.
Treatment
Referral to the nearest hospital (see the section on management of KS).
9.3.2.2. Squamous cell carcinoma of the conjunctiva
Description
This is a cancer of the eye arising from epithelial cells of the conjunctiva.
Clinical Features
It appears as a sessile or papillary growth on the intrapalpebral area of the
perilimbal conjunctiva In immuno- compromised patients, the tumour is
aggressive, with deep infiltration in the orbit and eyeball. Metastases occur to
the preauricular and submandibular lymph nodes
The predisposing factor is the immunocompromised host.
Signs
Early:
Usually, nasal limbal fungating growth in the region of an underlying
pinguicula or pterygium.
Late:
Huge fungating tumour of the orbit with metastases to local lymph nodes.
Treatment
Refer to the nearest eye specialist unit.
Early presentation:
Local excision with 2mm margin of the normal limbus.
May use local Mitomicin C (antimitotic)
291
Late presentation:
If the whole eyeball is involved with extension into the orbit, and vision is
lost - total exenteration.
Chemotherapy - if systemically spread.
Poor response to radiotherapy.
Retinoblastoma
(see Oncology chapter).
9.4.
COMMON EYE DISEASES ASSOCIATED WITH HIV/AIDS
Skin:
 Molluscum contagiosum of the eyelid
 Kaposi Sarcoma of the eyelid skin or conjunctiva
 Herpes zoster ophthalmicus
 Herpes simplex the eyelid skin
 Cornea Dendritic (Herpes simplex) corneal ulcers
 Fungal corneal ulcers
 Uvea Anterior uveitis - iritis
 Posterior uveitis - choroiditis or retinochoroiditis
 Pan uveitis
 Vitreous Candida vitritis
 Retinal vasculitis
 Cytomegalovirus Retinitis
 Neoplasia: Kaposi Sarcoma
 Squamous cell carcinoma
 Neuro-ophthalmic

Intracranial infections by pathogens such as Cryptococcus neoformans
and Toxoplasma gondii may cause ocular motor nerve palsies, papillary
abnormalities, visual field defects and optic neuropathy
9.4.1.
Moluscum Contangiosum
Description
This is a viral infection caused by the cytomegalovirus commonly affecting
children. The typical lesion is a pale, waxy elevated nodule on the eyelids.
Clinical Features
292
Complications
The shedding of cell-laden with viral particles can produce chronic follicular
conjunctivitis and superficial keratitis.
Treatment
Expression of the contents of the nodule
Heat cauterisation of the lesions.
9.4.2.
Herpes Zoster Ophthalmicus
Description
This is an infection caused by the varicella-zoster affecting the ophthalmic
division of the trigeminal vein. It is more common and more severe in
patients with lymphomas and those being treated by radiotherapy or immunosuppressed individuals.
Clinical Features
Symptoms
• Severe pain along the ophthalmic division of the trigeminal nerve VI)
• Maculopapular rash along the VI that obeys mid facial line.
• Swelling of the affected part of the face
Signs
• Typical Herpes Zoster rash
Complications
• Anterior uveitis
• Neurological: cranial nerve palsies
• Optic neuritis
• Encephalitis
• Contra-lateral hemiplegia
• Severe facial skin scarring
• Corneal opacification
• Neuropathic keratopathy
• Disciform keratopathy
Diagnosis
Clinical – the typical distribution of the Herpes Zoster rash
Treatment
• Oral acyclovir 800mg 5 times daily
293
•
•
•
•
•
Oxytetracycline 3% + Hydrocortisone 1% eye drops OR
Betamethasone 0.1% + Neomycin 0.5% eye drops OR
Dexamethasone 0.1% + Chloramphenicol 1% eye drops 4-6 times daily
Calamine lotion to the skin or Acyclovir 3% skin ointment
± systemic steroids (x-ray to rule out PTB) may activate TB in AIDS
patients
• Acyclovir 3% eye ointment 5 times daily.
9.4.3.
Cytomegalovirus Retinitis (CMV)
Description
This is a rare chronic diffuse exudative infection of the retina caused by the
CMV virus which occurs with rare exception, in patients with an impaired
immune system caused by either AIDS, cytotoxic chemotherapy or long term
immune suppression following organ transplantation.
Clinical Features
Symptoms
• Poor vision
• Floaters
Signs
• Cotton wool spots
• Full-thickness retinal necrosis and oedema which starts peripherally or at
the posterior pole
• Retinal bleeding
• Retinal vasculitis
• The whole retina eventually involved
• Total retinal atrophy
• Retinal detachment
Treatment
• Dihydroxypropoxymethyl guanine IV causes regression
• Ganciclovir IV infusion (induction) 5mg/kg 2 times a day for 12-21 days
Maintenance dose 5 mg/kg wt daily until adequate recovery of immunity
• Foscarnet IV infusion, induction 60mg/kg every 8 hours for 2-3 weeks,
then maintenance dose 60mg/kg daily increased to 90-120mg/kg if
tolerated. If CMW progresses while on the maintenance dose repeat the
induction dose. Treatment is needed for life
294
9.5.
OPTICS & REFRACTION (REFRACTIVE ERRORS AND
LOW VISION)
Description
This is a deficiency in the refracting mechanism of the eye resulting in poor
vision. The eye is designed to be able to perceive the light that falls within the
visible part of the electromagnetic spectrum. The two parts of the eye that are
responsible for image formation are:
a)
The Cornea – accounts for 2/3 of the refractive power of the eye.
b)
The Crystalline Lens which accounts for 1/3 of the refractive power
of the eye as well as for the accommodative capacity.
9.5.1.
Refractive Errors
Types of refractive error:
•
Myopia: - “short-sightedness”
•
Hyperopia:- (Hypermetropia) : Long-sightedness
•
Aphakia:- Poor vision that results from the absence of the
crystalline lens
•
Presbyopia:-Difficult in reading in the elderly (above 40 years) that
results from loss of the accommodative power of the lens
•
Astigmatism:- In this condition of the eye, the meridians of the eye
are not equal, resulting in unequal refraction
Clinical Features
Symptom
Poor vision
Sign
Specific retinal reflex in line with the types of refractive error mentioned
above on retinoscopy.
Refractive errors should be managed by optometrists, refractionists, and
opticians, including sometimes ophthalmic clinical officers, ophthalmic
nurses and ophthalmologists. After carrying out a visual acuity examination
on a patient complaining of poor vision, if the VA is found below 6/12 in the
better eye with maximum correction, the patient should be referred to the
nearest eye specialist where further assessment and management of such a
patient can be completed.
295
Treatment
•
Glasses, contact lenses, or reflective surgery sometimes
9.5.2.
Low Vision (VA range of 6/18 – 6/60)
Description
This is a failure to attain a visual improvement of more than 6/18 in the better
eye after being given the maximum conventional treatment for poor vision.
In such a patient further improvement of vision can be achieved by using low
visual aids.
Treatment
The types of low visual aids available are:
•
Optical – High power reading glasses, magnifies (illuminating and
non-illuminating), telescopes, closed-circuit television sets.
•
Non-optical – Environmental modification aimed at further
enhancing the corrected residue vision such as:
–
improving lighting‚
–
special reading stands‚
–
painting of the staircases to improve contrast,
–
painting kitchen utensils for ease of identification‚
–
special cheque signing cards‚
–
talking watches, etc.
Refer such a patient to higher centers where appropriate aid can be provided.
9.6.
STRABISMUS (SQUINT)
Description
This is ocular misalignment resulting from either an abnormality in binocular
vision or anomalies of neuromuscular control of ocular motor motility. When
eyes become dissociated (not aligned) then strabismus (squint) is present.
Orthophoria:
This is when the ocular motor apparatus is in perfect equilibrium so that both
eyes remain aligned (i.e. directed on the fixation point) in all positions of gaze
and at all distances of the fixation point even when the fusion mechanism is
disrupted such as when one eye is occluded. Orthophoria – describes
“essentially straight eyes.
Phorias:
296
These are latent deviations (latent strabismus or squint) or is a deviation kept
latent by the fusion mechanisms.
Tropias:
Are manifest deviations. A deviation (squint) that is
manifest at all times and is not kept under control by the fusion mechanisms
Types of Strabismus (squint)
• Esotropia: The eye is rotated so that the cornea is rotated nasally.
This is also known as convergent horizontal strabismus
• Exotropia: The eye is rotated so that the cornea is rotated temporally (i.e. on the temporal
side). This is also known as divergent horizontal strabismus
• Hypotropia: The eye is rotated about a transverse X-axis so that the cornea is rotated
inferiorly (downwards). This is also known as vertical strabismus
• Hypertropia: The eye is rotated about the transverse X-axis so that the cornea is rotated
superiorly (upwards). This is also known as vertical strabismus
Incyclotropia:
The eye is rotated about the sagittal Y axis so that the superior portion of the
vertical meridian is rotated nasally and the inferior portion of the vertical
meridian is rotated temporally. This is also known as torsional strabismus
• Excyclotropia:
The eye is rotated about the sagittal Y axis so that the superior portion of the
vertical meridian is rotated temporally (on the temporal side of the face) and
the inferior portion of the vertical meridian is rotated nasally (This one is also
torsional strabismus)
Classification
Several methods of classifying eye alignments and motility disorders are
used:
(1) Classification according to fusional status
• Phoria – a latent deviation in which fusion control is always present.
297
• Tropia – a manifest deviation in which fusion control is not present
• Intermittent – Fusion control is present at times
(2) Classification according to variation of the deviation with gaze position,
or fixating eye.
• Comitant – a deviation does not vary with the direction of gaze or fixating
gaze
• Incomitant – The deviation does vary with the direction of gaze or fixating
eye. Most incomitant strabismus is paralytic, indicating either
neurological or orbital disease.
(3) According to fixation :
• Alternating:
There is a spontaneous alteration of fixation from one eye to the other.
• Monocular – There is a definite preference of fixation with one eye.
(4)
According to the age of onset
• Congenital – a deviation noted (documented) before age of 6 months
• Acquired – an ocular deviation noted and documented after the age of 6
months.
(5)
According to the type of deviation
• Horizontal – Exo deviation or Eso deviation
• Vertical – hyper deviation or hypo deviation • Torsional – Incyclo
deviation or excyclo deviation or
• Combined
Treatment
This requires a specialized assessment that starts with a careful history,
clinical examination and treatment. Management requires the expertise of
orthoptists working hand in hand and under an ophthalmologist to treat these
unsightly ocular deviations.
A squinting child or an adult has an underlying problem that is responsible
for the deviation. It could be an abnormality of binocular vision or anomalies
of neuromuscular control of ocular motility. Some, if not all are treatable
provided these patients are referred and corrected early in life.
All squinting children should be referred to a specialist, preferably centers
that have Ophthalmologists.
298
9.7.
SYSTEMIC EYE DISEASES AND THE EYE
9.7.1.
Hypertensive Retinopathy
Description
The primary response of retinal arterioles to hypertension is narrowing. In
sustained hypertension, there is a disruption of the blood-retinal barrier
resulting in increased vascular permeability. The fundus picture of
hypertensive retinopathy is characterized by vasoconstriction, leakage and
arteriosclerosis.
Severe hypertension may lead to obstruction of the precapillary arterioles
leading to the development of cotton wool spots. Abnormal vascular
permeability leads to the development of flame-shaped haemorrhage, retinal
oedema and hard exudates. The deposition of hard exudates in the macular
area may lead to their radial distribution in form of a macular star. Swelling
of the optic nerve head is the hallmark of malignant hypertension. Arteriolar
sclerotic features are due to thickening of the blood vessel wall. The single
most important clinical sign is the presence of marked changes at the
arteriolar venous crossings.
Grading of Hypertensive retinopathy
Grade I: Mild generalized arteriolar constriction. Broadening of the arteriolar
light reflex and vein concealment.
Grade II: More severe generalized as well as focal arteriolar constriction and
deflection of veins at arteriolar/venous crossings.
Grade III: Flame-shaped haemorrhages, cotton wool spots, hard exudates,
copper-wiring of arterioles, banking of veins distal to the arteriolar/venous
crossings and right-angled deflections of veins.
Grade VI: Disc swelling and silver wiring of arterioles.
Treatment
Medical, Control of hypertension
9.7.2.
Retinal Vein Occlusion
Systemic hypertension is associated with an increased risk of both branch
retinal vein occlusion and central retinal artery occlusion.
Treatment
• No effective treatment
• Control the hypertension
• refer to an ophthalmologist
299
• Some patients develop secondary retinal neovascularization which
requires pan-retinal laser photocoagulation (Ischaemic type of central
retinal vein occlusion)
9.7.3.
Retinal Artery Occlusions
The patient may suffer attacks of amourosis fugax (transient absences of
vision) or frank retinal artery occlusion as a
result of the associated arteriosclerosis
Treatment
Requires urgent management
• the patient should lie flat
• Firm Ocular massage – to lower intraocular pressure, and increase retinal
blood flow
• Intravenous Acetazolamide 500mg start to further lower the intraocular
pressure
• Inhalation of a mixture of 5% Carbon dioxide and 95% Oxygen and
anterior chamber paracentesis.
Unfortunately, the results of the treatment are usually disappointing.
9.7.4.
Ocular motor palsies
Ocular muscle palsies may be found in patients with hypertension, even
though hypertension is not the only cause of ocular muscle palsies. There are
other causes like diabetes mellitus.
Treatment
Medical, control of hypertension
May undergo spontaneous resolution
9.7.2 Dysthyroid Eye disease
Description
Dysthyroid eye disease is a syndrome of clinical and orbital imaging
abnormalities caused by deposition of mucopolysaccharides and infiltration
with chronic inflammatory cells of the orbital tissues, particularly the
extraocular muscles.
Clinical Features
300
In general, the ocular features of Grave’ disease and ophthalmic euthyroid
graves’ disease are similar, although they tend to be more asymmetrical in the
latter stages.
Signs
Eyelid signs:
• Lid retraction
• Lid lag
Signs resulting from infiltrative ophthalmopathy
• Conjunctival injection (redness)
• Chemosis (swelling)
• Superior limbic conjunctivitis
• Proptosis
• Optic neuropathy whose early sign is colour desaturation
• Restrictive myopathy
Treatment
• Non-specific (reassurance, head elevation to reduce the severity of
periorbital oedema, taping of eyelids at night to protect the cornea,
prismatic glasses to reduce diplopia, diuretics such as Cyclopenthiazide
0.5mg at night to reduce morning periorbital oedema.
• Hypromellose 0.3mg (artificial tears) or SNO tears
• In severe cases, Prednisolone 80-100mg/day, enteric-coated and after
48hrs taper by 5mg every 5th day. Treat for a maximum of 2-8 weeks and
stop at 3 months
• Radiotherapy – used for patients who have systemic contraindications to
steroids, refuse steroids develop serious steroids side effect or a steroid
resistance.
• Dose – 20gy to the posterior orbit given for over a
10 day period
The response is usually evident within 6 weeks and maximum improvement
evident by 4 months.
• Orbital decompression; if the patient develops severe exposure
keratopathy, optic neuropathy or cosmetically unacceptable proptosis
• Surgery on Eyelids
–Tarsorrhaphy in uncontrolled exposure keratopathy
–To weaken muller’s muscle for a patient with severe lid retraction.
–Blepharoplasty
9.7.5.
Diabetic Retinopathy
301
Background
• Maculopathy
• Preproliferative
• Proliferative
Advanced diabetic eye disease
• Cataract
• Accelerated senile
• True diabetic
• Ocular Motor nerve palsies
• Abnormal pupillary reactions
• Changes in refraction
a) Diabetic Retinopathy (DR)
The overall prevalence of retinopathy in diabetic patients is about 25%. In
non-insulin-dependent diabetics (NIDDs), the prevalence is 20% while in
insulin-dependent diabetics, it is about 40%.
Predisposing factors (risk factors)
• The incidence of diabetic retinopathy is closely related to the duration of
diabetes. (generally more likely after 5 years’ onset of diabetes mellitus.
• Control of diabetes – poorly-controlled patients develop the complication
sooner than those well controlled.
• Pregnancy
• Hypertension
• Renal disease
• Anaemia
b) Background diabetic retinopathy (BDR)
Clinical Features
Signs
Mircroaneurysms at the posterior pole, temporal to the macula.
• Dot and blot haemorrhage
• Hard exudates
• Diffuse retinal oedema
Treatment
• Treat associated high Blood pressure, anaemia, renal
failure
• Monitor patients annually by retinal examinations. In some patients,
spontaneous regression occurs when diabetes is well controlled
302
c) Diabetic Maculopathy – results from macular oedema and hard exudates
Clinical Features
Symptoms
Gradual impairment of central vision
Difficult in reading small print
Signs
Features of BDR, plus foveal.
oedema, or foveal hard BDR, plus foveal oedema,
exudates
Treatment
Refer to Ophthalmologist
Laser macular grid
d) Preproliferative diabetic retinopathy (PPDR)
Clinical Features
Signs
• cotton wool spots
• Intraretinal microvascular angiopathies and segmentation
• Arteriolar narrowing
• Large blot and dot haemorrhages
Treatment
Refer to specialist
e) Proliferative diabetic retinopathy (PDR)
Clinical features
Signs
• Early neovascularization is seen on the disc, or elsewhere on the retina
• Late elevated new vessels, associated with a white fibrosis component.
Treatment
• Urgent referral to Ophthalmologist because they require Pan retinal
photocoagulation
f) Advanced Diabetic eye disease
303
Clinical Features
Symptoms
• Sudden onset of floaters
• Blurred vision from vitreous haemorrhage
Signs
• Dense Vitreous Haemorrhage
• Tractional retinal detachment
• Neovascular glaucoma
Treatment
Surgery
• Vitrectomy with endolaser photocoagulation
9.8. OCULAR EMERGENCIES
9.8.1.
Absolute Emergencies
• Chemical injury to the eye
• Cornea Laceration
• Hyphaema (Traumatic) absolute
9.8.1.1. Chemical Injury to the Eye (See section under Red-eye with pain).
9.8.1.2. Cornea Laceration
Description
Laceration if the Cornea
Clinical Features
Symptoms
• History of injury, Always ascertain the mode of injury
• Loss of vision following trauma
• Bleeding from the eye
Signs
• Obvious corneal laceration visible on direct light -examination of the eye
• Prolapsed iris is seen plugging the laceration
• The anterior chamber is flat with blood
• Eyeball is soft
Diagnosis
304
• Examining under local anaesthesia lignocaine 2% eye drops, gently
examine the eye under full aseptic condition. The aceration will be
visible.
Treatment
Early Management
• Tetanus Toxoid
• IM or IV Gentamycin 80mg start, or cefotaxime 1gm stat.
• Chloramphenicol 1% eye drops or Gentamycin 0.3% eye drops to
affected eye start
• Light dressing (padding) of the affected eye
• Refer to a specialist.
Specialist Management
• Under lignocaine 2%, examine the eye gently to ascertain the wound
shape.
• Exclude retained intraocular foreign body (x-ray or ultra-sound)
• Arrange for emergency repair, preferably under general anaesthesia.
• Suture the laceration under a microscope
• Reform the anterior chamber
• Sub-conjunctival injection of gentamycin o.3ml + atropine 0.3ml +
dexamethasone, 0.3ml
• Gentamycin, 0.3% eye drops 2 drops 4 times a day, or Chloramphenicol
1% eye drops 2 drops 4 times a day and keep eye padded.
9.8.1.3. Traumatic Hyphaema
Description
This is blood in the anterior chamber as a result of trauma, or very rarely
spontaneous. If spontaneous, rule out intraocular malignancy or juvenile
xanthogranuloma.
Clinical Features
Symptoms
• History of injury, usually blunt type of trauma
• Poor vision
Signs
Blood clots visible in the anterior chamber.
305
Treatment
• If the patient is a child admit in hospital and keep under observation. If
left unattended, chances of a re-bleed are high resulting in intraocular
pressure elevation and corneal staining
• If the anterior chamber is 1/3 full in an adult, can treat as an outpatient
• If the anterior chamber is full or 2/3 full, admit the patient
• Bed rest
• Betamethasone, or Dexamethasone 0.1% eye drops four times a day
• Induce cycloplegia, with Tropicamide 1% eye drop twice daily or
Atropine 1% eye drop once daily
• If intraocular pressure is elevated, use antiglaucoma drops, preferably
Timolol 0.5% two drops or oral Acetazolamide 250mg tablets 4 times
daily
• Use topical antibiotic to prevent or treat the associated infection
• Chloramphenicol 1% or Gentamycin, 0.3% eye drops
9.8.2.
Relative Emergencies
• Congenital cataract
• Retinal detachment
Refer to the Specialists early.
9.9.
GLAUCOMA
Description
This is a group of diseases in which the intraocular pressure is sufficiently
elevated to damage vision
Types
(i)Primary
(ii)Secondary
(iii)Congenital
9.9.1.
Primary angle closure (congestive) Glaucoma
(See the section on Red-eye with Pain)
9.9.2.
Primary open-angle glaucoma
(chronic simple glaucoma)
306
Description
This is a prolonged increase in ocular pressure. The result is complete damage
to the optic nerve.
Clinical Features
Symptoms
• Usually asymptomatic
Signs
• Gonioscopy – normal angle
• on Tonometry, Intra-ocular-pressure (IOP) will be raised, above
25mmHg
• Optic nerve cupping
• Visual field – trachoma type of visual field loss
• Late - When blind – Optic atrophy
Investigations
• perimetry – Peripheral visual field analysis, either by confrontation or
using Peripheral visual field analyzer
• Tonometry – Perkins or Goldman
• Gonioscopy – Normal angle
• Fundoscopy – optic disc cupping
Treatment
1st Line
Timolol maleate 0.25% or 0.5% twice daily
Rule out underlining cardiac or pulmonary malfunction
2nd Line
Pilocarpine 2% or 4% eye drops 4 times daily
Dipivefrine 0.1% eye drops twice daily
3rd line
Latanoprost 50 micrograms/ml once or twice daily
Acetazolamide 250mg (slow release) tablet once daily. Use only for a short
while.
Treatment is for life as long as the compliance stays good and as long as intraocular pressure is controlled. Ocular association of Primary open-angle
glaucoma (POAG) (recommend to rule out glaucoma in any of these
conditions:)
307
•
•
•
•
High myopia
Retinal vein occlusion
Retinal detachment
Pigmentary Retinopathy of retinitis pigmentosa type
Systemic associations
• Diabetes Mellitus
• Dysthyroid ophthalmopathy
Current practice recommends surgery as 1st line management because of poor
compliance of treatment for life. Trabeculectomy (Filtration surgery) ± use
Mitomycin C.
DO NOT DISCHARGE PATIENT. SEE AT LEAST TWICE YEARLY.
TO SAFEGUARD AGAINST SECONDARY CLOSURE OF THE
FILTRATION BLEP.
9.9.3.
Primary Congenital Glaucoma
Description
This is intraocular pressure elevation in a child, that manifest either at birth
or a few years after birth due to a developmental anomaly of the formation of
the eye anterior chamber angle.
Clinical Features
Symptoms
• Lacrimation (usually mistaken for lacrimal duct closure
• Light intolerance
Signs
• Large eye – Buphthalmos
• Misty looking cornea
• Haab's striae on the cornea (on slit-lamp microscopy)
• Cuped disc
Investigation
• Corneal diameters (7 – 11mm) 16 over 11mm, a reason to be suspicious
• Refraction: myopic
• Tonometry – Intraocular pressure will be high
308
• Fundoscopy – varying degrees of cupping
Treatment
• Surgical – Trabeculectomy
• Goniotomy
9.9.3.1. Secondary glaucomas
Description
These are glaucomas that are secondary to an underlying cause.
Treatment
Refer to eye specialist services.
309
10.
ANAEMIA AND NUTRITIONAL
CONDITIONS
10.1. ANAEMIA
Description
This is a reduction in the haemoglobin concentration in an individual to below
the normal range for that individual’s age and sex.
The normal haemoglobin concentration ranges are as follows:
Male
130 –
adults
180g/L
Female
adults
(Non
120
pregnant)
160g/L
Children
135 –
Birth (full
195g/L
term)
+/- 30
6 weeks
110 –
170g/L
2 - 6
months
115 –
155g/L
2 - 6
years
110 –
140g/L
7-12
years
110 –
150g/L
Anaemia is not a diagnosis in itself as there is always an underlying cause,
which must be determined before the anaemia can be properly treated.
Anaemia is most often detected by measuring the haemoglobin (Hb)
concentration of the blood.
In the management of anaemia, one must obtain a detailed history from the
patient or caregivers, examine the anaemic patient carefully and perform the
appropriate investigations with a view of:
1.Establishing that the patient is anaemic
2.Establishing the type of anaemia the patient has
3.Determining the cause of the anaemia
4.Determining whether or not complications are arising from the anaemia, the
cause of the anaemia or both.
310
The history obtained from the patient or caregivers often gives very important
information for making an appropriate diagnosis.
Once the type of anaemia and its cause have been established, appropriate
treatment can be given and, where possible, the underlying cause corrected or
removed.
One principal function of the red blood cells is to carry oxygen from the lungs
to all other areas of the body and this function is performed by the
haemoglobin. The haemoglobin, found in the red blood cells, binds to oxygen
in the lungs and the haemoglobin bound oxygen is transported to other organs
where is it released. When the haemoglobin concentration is low, the oxygencarrying capacity of the blood is reduced and thus the amount of oxygen
reaching other organs is also reduced. In anaemic states, the body will thus
react in such a way as to try to maintain the levels of oxygen reaching the
organs.
Clinical features
The clinical features of anaemia are directly due to the lowered haemoglobin
concentration and are therefore common to all types of anaemia irrespective
of the cause.
Symptoms
• Tiredness, weakness, dizziness, shortness of breath and headache,
palpitations visual disturbances
Signs
• One general sign of anaemia is pallor of the mucous membranes, and nail
beds, However, this sign is unreliable as it can be masked by other
conditions such as jaundice and conjunctivitis.
• Other signs will be of either the underlying cause e.g., bruising of the skin
in aplastic anaemia or the effects of anaemia such as heart failure.
Classification of Anaemia
There are several methods of classifying anaemia but the most common is
based upon the cause of the anaemia. Anaemia can result from:
1. Poor production of red blood cells
2.Increased destruction of the red blood cells
3.Increased loss of red blood cells from the body
311
Anaemia that arises from poor production of red blood cells include:
• Nutritional deficiency anaemias such as iron, folic acid and vitamin B12
deficiency anaemias, anaemia of chronic illness and bone marrow failure
syndromes such as aplastic anaemia, invasion of the bone marrow by
cancer, infection in the bone marrow
• Anaemias arising from increased red blood cell destruction include sickle
cell anaemia, infections such as malaria, auto-immune haemolytic
anaemia, G-6-PD deficiency. Increased blood loss may result from
parasitic infestations such as hookworm, and schistosomiasis, heavy
menstrual loss and surgical conditions such as bleeding peptic ulcers.
Nutritional anaemia
Iron deficiency anaemia
Iron deficiency anaemia is by far the most common type of anaemia in the
world. Hookworm infestation and schistosomiasis not only cause anaemia by
whole blood loss but they are also leading causes of iron deficiency in
developing countries. Iron deficiency may also arise from poor dietary
intake, malabsorption or increased demands as in pregnancy
Folic acid and Vitamin B12 deficiency
Deficiency of either or both of these micronutrients results in anaemias
characterised by larger than normal red blood cells (megaloblastic anaemias).
Megaloblastic anaemias may arise from increased demands for the
micronutrients as may occur in pregnancy and lactation, haemolysis, poor
dietary intake particularly in absolute vegetarians (Vit B 12) and
malabsorption
Diagnosis
• FBC, peripheral smear
• Urinalysis + Microscopy
• Stool for occult blood, ova and parasites
• Other investigations will be dependent on the clinical ‚ evaluation of the
patient
10.1.1.
Treatment of nutritional anaemia
Drugs
Ferrous Sulphate, Adults 200mg 3 times a day after meals until the Hb has
reached the normal range. Continue with 200mg daily for 6 months to build
up iron stores.
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Children up to 1 year:
Ferrous Sulphate 9-18mg of iron daily (0.75ml-1.5 ml mixture).
1-5 years:
100-150mg daily (10-15ml mixture daily) in divided doses. 6-12 years:
200mg 3 times a day.
For prophylaxis 200mg 3 times daily
Iron Dextran injection to be used in a hospital under the direct supervision of
a doctor. It is not superior to oral iron and is used only when patients cannot
tolerate oral therapy.
Folic Acid 5-10mg daily for as long as required. Vitamin B12
(Hydroxocobalamin) injection, initially 1mg I.V. repeated 5 times at intervals
of 2-3 days. Maintenance dose 1mg every 2-3 months. Lifelong treatment
may be required.
10.2. MALNUTRITION
Description
Malnutrition is a term that covers a wide range of clinical conditions in
children and adults causing impairment of health. It results from a deficiency
or an excess of one or more essential nutrients. Malnourished individuals are
prone to infections and in children, it causes poor growth.
In pregnancy, poor nutrition results in the birth of low weight babies.
Protein Energy Malnutrition (PEM)
This is the commonest form of malnutrition in children below 5 years of age.
It is a result of deficiencies in any or all nutrients (macro and micronutrients)
The first sign is the loss of weight or failure to gain weight. The children
under-five card helps us to detect this form of malnutrition at the clinic
through growth monitoring.
There are three main clinical syndromes:
1. Kwashiorkor
2. Marasmic-kwashiorkor
3. Marasmus
Underweight represents the mildest form of malnutrition while kwashiorkor,
marasmus and marasmus-kwashiorkor represent the severe forms and require
admission in the health centre or hospital for treatment.
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Underweight Marasmus
Kwashiorkor 70-60% Marasmic-Kwashiorkor with oedema Marasmus
Below 60% without oedema
The child has gross muscle wasting, no subcutaneous fat, has a hungry and
anxious look.
Kwashiorkor 80-60%
The child shows oedema, flaky paint rash; thin, pale sparse easily pluckable
hair, apathetic, anorexic, moonfaced. Big fatty liver on palpitation
Marasmic-kwashiorkor 60-70%
Wasted body but also has oedema. This is severe malnutrition and usually
requires admission in the health centre or hospital for treatment.
Treatment
For patients with very severe malnutrition, including its complications, admit
to hospital and treat with F75 and F100 as nutritional replacement feeds.
Patients with mild or moderate disease can be treated at the community level
using RUFT (plumpy nut).
Procedures on admission
1.Weigh the child
2.Record temperature (rectal), pulse, respiration rate
3.Check blood sugar (Dextrostix)
4.FBC/ESR, electrolytes, urea, serum protein/albumin, sugar and MP
5.Stool and urine
6.
Mantoux, CXR
Resuscitation
a) Resuscitation first 4-7 days. Most deaths occur in this period.
b) Generally keep warm with heater and hot water bottles.
– Do not give a bath
– Nurse away from windows
–Adequate covering during the night (most kwashiorkor babies die at night).
c)Start feeding immediately after admission with F75.
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Oral:
Use a cup and spoon. For a very sick and anorexic child, careful continuous
nasogastric tube feeding can be used.
Milk Diet:
100ml/kg increasing to 150ml/kg in 7 divided doses.
The milk diet is made from:
Dried skimmed milk
120g
Sugar
30g
Oil
35g
Electrolyte solution 30 ml
Add cooled boiled water slowly up to 1 litre. Stir well.
Electrolyte Solution made up of:
Potassium chloride 90g
Magnesium hydroxide 9g
Cooled boiled water 100ml
Only 30ml of the Electrolyte solution is used for each litre of milk diet made.
d)Rehydration, severe dehydration can be present despite oedema.
Give half-strength Darrow's with dextrose, 20ml/kg in the first hour. 20ml/kg
over the next 2 hours, followed by 5 – 10ml/kg per hour depending on the
severity of the dehydration.
In less severe dehydration and when an IV line is not possible, give ORS, 5080ml/kg over 4-6 hours followed by milk diet.
e) Drugs Potassium:
6 mEq/kg per day for 2 weeks or more, particularly in a child with chronic
diarrhoea. Give potassium as potassium citrate, or potassium chloride.
Magnesium sulphate 25% IM 0.2g for 3-5 days,
Vitamin A 6 drops (30.000 IU) stat followed by one drop (5.000 IU) daily
given with water or milk. If there are signs of keratomalacia give 1ml or 30
drops (150.000 IU) orally stat.
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Folic Acid 5 mg daily
Vitamin K injection 5mg stat on admission
Antibiotics: Gentamycin
Multivitamin syrup
Note: Iron-containing syrup should be avoided in the acute phase of
malnutrition.
Complications
1. Hypothermia:
With temperature below 35.5 0C, mortality doubles. Warm up the child.
Monitor temperature every hour until the temperature reaches 37 0C, then take
every 4 hours.
2.Hypoglycaemia:
If blood sugar is below 2.2mmol/l (or below 2.5mmol/1 by dextrostix)
mortality increases by about 4 times. May be asymptomatic.
Treatment
• Dextrose 25% IV 2ml/kg or dextrose 50% 1ml/kg followed by IV drip of
10% dextrose 75ml/kg/day. Reduce gradually as the blood sugar
stabilises.
• Monitor blood sugar with dextrostix 4 hourly until normal and stable.
• Heart failure: May be precipitated by severe anaemia or excessive fluids
given IV or orally. This condition is common in the second week of
treatment.
Complications
Suspect heart failure if oedema disappears but weight is constant, or sudden
rapid weight gain, or increase of pulse. Check size of the liver.
Treatment (heart failure)
• Diuretic (Furosemide 1mg/kg).
• Blood transfusion to anaemic children (4-6 g%), 20ml/kg slowly. If CCF
present, Hb below 4 g/dl give 10ml/kg or packed cells slowly.
Convulsions: Diazepam to stop convulsions. Do Lumbar Puncture,
dextrostix, electrolytes and Blood Slide.
Diarrhoea: Check stool for reducing sugars. If positive, change to lactose-free
milk.
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If there is no evidence of reducing sugars in stool continue with a milk diet.
Treat any parasites, e.g. giardiasis.
• Metronidazole 100mg 3 times daily for 5 days
• Mebendazole 100mg 2 times daily
Rehabilitation
2-6 weeks of gradually increasing the energy and protein intake to 200-300
kcals/kg per day (normal requirement 100-110 kcals per day) and protein 4-5
g/kg per day (normal requirement 2g/kg per day).
As soon as the child wants food put on a normal diet in addition to his full
requirement of milk diet.
10.3. VITAMIN DEFICIENCIES
Vitamins are compounds needed in small quantities for the operation of
normal bodily metabolism. The vitamin requirements may be increased
during disease and fevers. Vitamin deficiency may appear as single or
combined conditions. Multivitamin preparations will cover mild deficiencies
of a combined nature. Vitamin B complex preparations will often cover most
of the vitamin B deficiencies.
Note that a diet with sufficient fruit and vegetables will prevent most vitamin
deficiencies.
10.3.1.
Vitamin A
Sources of Vitamin A: Mangoes, pawpaw, carrots, spinach, cod liver oil.
Deficiency leads to:
• Dryness of conjunctiva (Xerosis)
• The scariness of the skin and sometimes acne
• Keratisation of the cornea, cortical opacity and blindness
• Inability to see easily in the dark (night blindness),
• Softening of the cornea (keratomalacia) often followed by cortical
perforation and panophthalmitis.
Treatment
• Children with severe malnutrition, give one age-specific dose (see under
malnutrition above)
• Children with diarrhoea for more than 3 days and children with measles
give one dose
Prevention
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• 6 - 11 months give 100,000 i.u. once
• 12 - 72 months give 200,000 i.u. once every six months
10.3.2. Vitamin B group
a) Vitamin Bl
May cause neuropathy in adults and cardiac failure in babies (Beri-beri)
b) Vitamin B2 (Riboflavin).
Deficiency causes mucocutaneous lesions such as angular stomatitis, sore
cracked lips, and glossitis
c) Nicotinic Acid.
Deficiency leads to pellagra, a disease common in adults and recognisable by
the so-called “3 Ds”:
Dermatitis:
Skin developing a cracked, pigmented scariness in the areas exposed to sun
or mechanical irritation.
Diarrhoea:
Gastrointestinal symptoms of loose watery stools.
Dementia:
Neurological symptoms, usually severe in adults but showing as apathy and
irritability in children.
Treatment
• Vitamin B1 25 – 100mg i.m. or orally
• Vitamin B2: 5 – 10mg daily
• Nicotinamide 100-300mg daily
• Until symptoms disappear
10.3.3. Vitamin C (Ascorbic acid)
Sources of ascorbic acid: Oranges, lemons, green vegetables. Deficiency
leads to scurvy, a disease recognised by:
Clinical features
Signs and Symptoms
• Periodontal haemorrhage
• Swelling and pain of long bones due to sub- periodontal haemorrhage
• Loosening of teeth and lesions of the gums
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• Leading to infections in the mouth.
Treatment
• Vitamin C tablets (Ascorbic acid) 200mg 4 times daily.
• Until symptoms disappear.
10.3.4. Vitamin D
Sources of vitamin D: Milk, butter, eggs, cod liver oil. It is normally formed
in the skin from sunlight.
Clinical Features
Signs and Symptoms
Deficiency leads to rickets, recognised by:
• Softening of bones resulting in bowing of legs or knock-knees.
• Thickening of the ends of bones.
Treatment
• Vitamin D, 1000-5000 units/day orally for a period of 6 weeks to 3
months.
• Exposure to sunlight
Prevention
• Prevention of malnutrition requires the administration of a variety of
foods providing a balanced or mixed diet to satisfy the individual
nutritional needs.
Guidance concerning locally produced foods of the different food groups is
important. People should be educated on the importance of eating regular
nutritious meals including fruits and vegetables.
Pregnant women Encouraged to:
• Eat a well-balanced diet. (enough quantity of foods daily to meet her daily
energy and enough critical nutrients needs, comply with the micronutrient
supplement – Essential nutrition)
• Have extra rest especially during the third trimester.
• Space their pregnancies (child-spacing 3yrs) adequately through the use
of family planning methods. And must know their HIV status to safely
breastfeed her child
Infant and Young Children
• Initiate breastfeeding within an hour of birth
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• Exclusively breastfeed for the first 6 months
A timely introduction to complementary feeding (from 6 months with
continued breastfeeding up to 24 months and beyond) and follow
complementary feeding guidelines (Frequency of feeds according to the age
group, density, utilization of food by vitamins and active feeding) after 6
months with continued breastfeeding until 18-24 months. To the porridge
should be added protein foods e.g. legumes (beans, peas, groundnuts), fish,
meat.
• Pre-school children should be fed 4-5 times a day
• Children should be fed even when they are sick
• Children should be given fruits and vegetable regularly
• Encourage immunisation
For episodes of diarrhoea in breastfed young children intensify breastfeeding
for and promote the use of ORS according to the severity of the diarrhoea.
Early detection of children developing malnutrition (not gaining weight or
loss of weight) and institutional high protein and high-calorie diet.
10.4. VULNERABLE GROUP FEEDING
The supplementary rations given to selected vulnerable or at-risk groups to
make up for deficiencies in the diet should be instituted temporarily.
Meanwhile, permanent home-based ways to make the diet adequate should
be sought.
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11.
DERMATOLOGICAL CONDITIONS
These are classified according to the cause of infection or infestation:
• Bacterial infections
• Fungal infections
• Viral infections
• Parasitic infestations
11.1. BACTERIAL INFECTIONS
Description
This is a condition caused by blocked sebaceous glands. It usually begins at
or after puberty. The most affected parts are the face, neck, back and chest.
Clinical features
Occurs in mild form as blackheads and whiteheads (closed comedones and
open comedones) and more severe form as nodular lesions, with or without
infection
Treatment
Drugs
• Benzoyl peroxide gel 2.5-10% topically 1- 2 times daily
• Doxycycline, 50-l00mg orally daily for 6 weeks in severe cases
Supportive
• Wash the affected parts with carbolic soap and water
2 to 3 times daily
• Avoid the use of cosmetics
• Diet should include plenty of fruits and vegetables
• Avoid fatty foods
11.1.2.
Abscess
Description
This is a collection of pus in the dermis and subcutaneous fat layer of the skin.
It occurs as a result of infection of the hair follicles commonly caused by
Staphylococcus aureus.
Clinical features
321
The skin surrounding the affected hair follicle becomes red, hot, swollen and
tender to touch. In severe cases, there will be fever and involvement of the
local lymph nodes
Treatment
Drugs
• Cloxacillin, adults; 250 - 500mg orally. 6 hourly for 5 days, children; 125
- 250mg orally 6 hourly five days or
• Erythromycin, adults; 250 - 500mg orally 6 hourly for 5 days, children;
125-250mg orally 6 hourly for 5 days
Surgery
• Incision and drainage
• In cases of multiple abscesses, non-response to antibiotic therapy or an
abscess in a diabetic, refer to a specialist
Supportive
• Encourage patient to maintain good general hygiene
• Apply hot compression 3-4 times daily until abscess ƒ is ready for
draining.
11.1.3.
Impetigo
Description
This is a superficial infection of the epidermal layer of the skin by aureus
commonly but Streptococcus species may also be involved. Painful vesicles
and pustules break down to form scabs or crusts. Impetigo starts on the face
and may spread to the neck, hands and legs. It usually occurs in children.
Treatment
Drugs
• Cloxacillin, orally, adults; 250 - 500mg 6 hourly for
5 days, children; 125 -250mg 6 hourly for 5 days or
• Erythromycin, orally, adults; 250 - 500mg 6 hourly for 5 days, children;
125 -250mg 6 hourly for 5 days
Supportive
• Keep fingernails short
• Soak and clean pustules with water and soap
• The patient should be referred to the next level if there is no improvement
after 2 weeks
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11.1.4.
Eczema
Description
Eczema is an inflammatory rash which may be due to endogenous or
exogenous factors.
Classification of Eczema:
• Endogenous
–Atopic (inherited disposition)
–Seborrhoeic
–Asteatosis
–Discoid (nummular)
–Unclassified
• Exogenous
–Allergic contact dermatitis
–Primary irritant dermatitis
–Photo dermatitis
11.1.4.1. Atopic eczema
Description
This is a condition characterised by an itchy, rough, dry skin. In babies, it
occurs mainly in the areas surrounding the knees, elbows and neck whereas
in older children and adults it can occur on any part of the body. The itching
is intense at night and could become chronic and infected. Where possible the
causative factor should be determined before commencing treatment.
Treatment
Drugs
• Aqueous cream, topically 1-3 times daily after bathing or
• Zinc oxide cream, topically 1-3 times daily after bathing
• Betamethasone 1%, topically twice daily for 7 days
(for severe or non-responsive cases) or
• Hydrocortisone in, topically twice daily for 7 days
• Zinc and Coal Tar Paste, topically 1 -2 times daily (in chronic cases)
• Chlorpheniramine 4mg 2 times a day
• Erythromycin 500mg 4 times a day for 7 days
Supportive
• Keep fingernails short
• Keep skin hydrated with Oil bath
• The patient should avoid scratching
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• Avoid exposure of affected parts to sunlight
• Avoid known irritants e.g. soap, woollen clothing. If there is no
improvement in the acute condition after 2 weeks refer to a specialist.
11.1.4.2. Seborrhoeic eczema
Description
This is a condition characterized by thick adherent scales presenting as a
diffuse scaly scalp (dandruff). It may also affect other parts of the body which
tend to be oily e.g. facial skin nasolabial folds, eyebrows, eyelashes, external
ears, and centre of the back. Variable pruritis and vesicular or scaly lesions
may be present.
Infantile seborrhoeic eczema occurs in early infancy 24 weeks after birth.
Begins with cradle cap (scaly scalp surrounding the anterior fontanelle),
spreads to the face, axilla, neck and nappy area. The rash is non-itchy and gets
better without leaving marks.
Treatment
Drugs
Hydrocortisone 1% cream, topically twice daily; Maintenance;
once or twice a week as required
Zinc oxide cream, topically 1-3 times daily after bathing especially
in the nappy area or
Aqueous cream, topically 1-3 times daily after bathing.
To reduce scaling and itching of the scalp use keratolytic or antifungal
containing shampoos once or twice weekly. Refer patients who do not
respond to treatment or have acute oozing eczema to a specialist.
11.2.
FUNGAL INFECTIONS
Superficial fungi live in the stratum corneum and feed on the keratin. They
are called dermatophytes and belong to 3 genera as follows: Microsporum,
Trichophyton, and Epidermophyton, respectively. More than 40 species are
currently recognized with 10 causing human infection. They are transmitted
from person to person by direct body contact or by fomites e.g. combs. They
can also be transmitted from animals such as cats and dogs(zoophilic) or from
the soil and plants (geophilic) The infections are named according to the body
parts affected as follows:
• Tinea pedis – feet
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•
•
•
•
•
•
•
•
•
•
Tinea corporis – body
Tinea capitis – scalp and hair
Tinea manus – hands
Tinea unguium – nails
Tinea cruris – groin area covering the T of the genital area extending
behind
along the gluteal cleft
Tinea facialis – face
Tinea barbae – beard area
Tinea versicolor
Cutaneous candidiasis
11.2.1. Tinea pedis (athletes foot)
Description
This is a contagious fungal infection of the foot caused by Trichophyton
mentagrophytes and T. rubrum most commonly.
Clinical features
• Itching of the foot
• Burning or stinging lesions with scaling borders between the toes
• Vesicular eruptions with white scaling between the 4 th or 5th toes or the
instep of the sole
• May be accompanied by vesicles on the palms and sides of fingers called
‘id’ reaction. The vesicles do not contain fungus and get better when the
fungus is treated
Diagnosis
Scrape the scales from the infected site and put on a glass slide with a drop of
20% KOH. On microscopy branching, fungal hyphae are seen.
Treatment
Drugs
Miconazole 2% cream, topically twice daily
Continue treatment for 2 weeks after the symptoms have cleared.
Supportive
• Keep feet dry all the time
• Wear open footwear
• Wear cotton socks, if need be
• Change socks daily
325
11.2.2. Tinea corporis (ringworm of body, trunk and limbs)
Description
This is a condition which can be acquired from animal (Trichophyton
verrucossum, Microsporum canis) or human contact (T. rubrum). It is
characterised by itchy lesions appearing as scaly greyish patches with raised
borders. It can affect any part of the body, with the most commonly affected
parts being the arms, groin, buttocks, waist and the area under the breasts.
Treatment
Drugs
• Miconazole cream 2%, topically twice daily for 2 to 6 weeks.
• Fluconazole 200mg O.D. oral for 6 weeks
• Griseofulvin 500mg O.D. oral up to 2 weeks after lesions disappear
Supportive
• Maintenance of general hygiene
• Avoid sharing of personal items such as towels and clothes.
11.2.3. Tinea capitis (scalp ringworm)
This is a fungal infection of the scalp which is especially common in children.
It is caused by Trichophyton species – violaceum in Africa and Asia, T.
rubrum in Europe. Non-inflammatory invasion of the hair shaft can occur due
to Microsporum audouiini transferred by contact with barber shears, hats or
M. canis from pets.
Clinical features
• Diffuse scaling of the scalp with no hair loss
• Circular scaly patches in the scalp with associated alopecia (hair loss)
• In severe cases, a boggy swollen mass with discharging pus and exudates
called Kerion is due to animal fungus.
Diagnosis
Remove scales and broken hairs with a blunt scalpel and put it on a slide with
Potassium Hydroxide 20%. The hair shaft is seen under the microscope full
of fungal spores.
Treatment
Drugs
326
• Griseofulvin, adults; 500mg orally daily as a single dose or in divided
doses (in severe infection dose may be doubled, reducing when the
response occurs), children; l0mg/kg body weight daily as a single
dose or in divided doses continue till two weeks after the lesions disappear
and hair is growing.
Supportive
• Maintenance of good general hygiene
• Avoid sharing of personal items such as towels and clothes
• Keep hair short
11.2.4. Cutaneous Candidiasis
Description
This is an infection of the skin caused by Candida albicans a yeast fungus
which is a normal commensal occupying the gut. Under certain circumstances
such as diabetes or other endocrine diseases or immunosuppressive states, it
becomes pathogenic. The infection usually occurs in the skin folds such as,
around the groin area, under the breasts, in the nail folds and axilla. In chronic
or severe cases suspect HIV/AIDS.
Clinical features
Moist, white curd-like papules and plaques form which are easily scraped off
leaving red and raw-looking patches with clear edges.
Diagnosis
Scrape off white patch and place on a glass slide with a drop of Potassium
hydroxide (KOH). Hyphae and yeast are seen.
Treatment
Drugs
• Miconazole cream 2%, topically twice daily.
Continue treatment for 14 days after lesions have healed.
For nail infections, apply under occlusive dressing.
Supportive
• The patient should be advised to keep the skin dry
• Long-term antibiotic use should be avoided
Patients not responding to topical applications should be referred to a
specialist.
327
11.3.
VIRAL SKIN INFECTIONS
These include:
• Chickenpox
• Herpes zoster
• Herpes simplex
11.3.1.
Chickenpox
Description
This is a condition caused by the Varicella zoster virus (VZV). It is a common
childhood infection. It is characterized by an itchy rash, which appears first
on the trunk and spreads out to other parts of the body. Papules and crusts
form within a few days. Fever may be present. When the blisters occur they
are in crops. The rash lasts 2 to 4 weeks. The condition is usually more severe
in the elderly.
Diagnosis
Diagnosis is usually done clinically.
Treatment
Drugs
• Calamine lotion, topically twice daily or
• Chlorpheniramine, adults; 4mg orally twice daily, children up to 10 years;
2mg orally twice daily
• Acyclovir, 800mg orally 5 times daily for 7 days
• Paracetamol, adults; 500mg - 1g orally 3-4 times daily, children; 1020mg/kg orally 3-4 times daily
11.3.2.
Herpes Zoster
Description
This is a condition caused by the resurgence of the Varicella zoster virus. It
is characterised by burning pain before the vesicular rash appears. The rash is
always unilateral and does not cross the midline (see section 8.8,
malignancies).
Treatment
Drugs
• Paracetamol 500mg - 1g orally 3 - 4 times daily.
• Gentian violet may be applied
328
• Acyclovir 5%, topically 4 hourly for 10 days.
• Acyclovir 800mg orally 5 times daily for 7 days.
• Carbamazepine 200-400mg orally 3 times daily.
(for post herpetic neuralgia)
Treat secondary bacterial infection with appropriate antibiotics.
Severe neuralgia should be referred to a neurologist.
11.3.3.
Herpes Simplex
Description
This is a condition caused by Herpes simplex virus (HSV) type 1
characterised by a vesicular rash around the mouth or genitalia.
Treatment
Drugs
• Usually, no drug therapy is required
• Wash lesions with saline water
• Paracetamol, adults; 500mg-1 g orally 3-4 times daily, children; 1020mg/kg orally 3-4 times daily
• Acyclovir cream, 4 hourly.
11.4. PARASITIC INFESTATIONS
Description
Parasitic infestations of the body include:
• Pediculosis
• Scabies
11.4.1. Pediculosis (lice)
Description
This is the infestation of the hair or body with lice. Hair infestation (Pediculus
humanus var capitis) is characterised by eggs (nits) which appear as small
white specks attached to the hair. Body infestation ( P. humanus corporis) is
characterised by bite marks. Both hair and body infestations cause itching.
Eczema may be present. The lice usually live in cloth folds. An infestation of
the pubic area called Pediculosis pubis is caused by the crab or pubic louse
Pthirus pubis transmitted during close physical contact which may be sexual
in nature.
329
Treatment
Drugs
• Malathion 0.5% lotion. Apply to affected parts. Let it dry naturally and
remove by washing after 12 hours.
• Permethrin 1% cream. Apply to clean damp hair.
• Rinse after 10 minutes and dry.
Supportive
• The whole family should be examined and treated if possible
• Bed linen and clothes should be washed in warm water and dried in the
sun
• Maintenance of good personal hygiene.
11.4.2. Scabies
Description
This is an infestation of the skin by mites, Sarcoptes scabies, which burrow
the skin causing lesions where the female rests and lays eggs. The most
common sites are skin folds, wrists, in between fingers and axilla. The main
characteristic is intense itching which worsens at night.
Treatment
Drugs
• Benzyl Benzoate 25%, applied all over the body from the neck
downwards. Leave to dry and repeat without bathing after 24 hours. Wash
off on the third day. A third application may be required.
(Not
recommended in children, pregnancy and breastfeeding mothers) or
• Permethrin cream 5%, applied all over the body from the neck down to
the feet. Wash off after 8 to 24 hours
• For children apply all over the body including the face, neck, scalp and
ears
• If hands are washed with soap within 8 hours of application, the cream
should be re-applied or
• Malathion 0.5% lotion. Apply all over the body and wash off after 24
hours.
Supportive
• All members of the family should be examined and treated (if possible).
• Clothes and bedding should be washed in warm water and dried in the
sun.
• After treatment, only clothes washed as above should be worn.
330
• Discourage scratching.
• Keep fingernails short and clean.
331
12.
CONDITIONS OF THE EAR, NOSE AND
OROPHARYNX
These include:
• Oral diseases
• Pharyngeal diseases
• Nasal diseases
• Ear conditions
12.1. ORAL DISEASES
These include:
• Dental caries
• Periodontal disease
• Oral candidiasis
• Herpes simplex stomatitis
• Mouth ulcers
12.1.1.
Dental caries
Description
This is a sugar-dependent disease, which by a combination of chemical and
bacterial action, progressively destroys the enamel of the tooth. Many bacteria
ferment sugar to produce acid, which in turn causes lesions on the enamel of
the tooth.
Clinical features
• Chalky white spots on the chewing surface of the tooth
• Sensitivity of tooth to cold or hot drinks and foods
• Cavity on the tooth
• Pain
• Swelling at the base of the tooth if pulp nerve roots are involved
• Fever
Treatment
Treatment aims to preserve the tooth as far as possible.
Drugs used in infections, complicated extractions or prophylaxis:
• Phenoxymethyl penicillin, adults; 250-750mg orally 6 hourly, children; 1
– 5 years; 125mg orally 6 hourly, 6 – 12 years; 250mg orally 6 hourly
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• Paracetamol, adults; 500mg -1g orally 3 times daily, children; 1020mg/kg orally 3 times daily or
• Aspirin, adults; 600mg orally 3 times daily (Not recommended for
children)
Conservation
• Tooth filling
• Root canal treatment if the pulp is affected
Surgical
• Extraction
• Apicectomy
Prevention
• Encourage maintenance of good oral hygiene
• Reduce the intake of sugary foods
• Use of fluoride-containing toothpaste
• Use of mouth rinses containing fluoride
• Use of topical fluoride applications
• Use of sealants in children, where available
• Dental check at least twice a year
12.1.2.
Periodontal disease
Description
This is a pathological condition of the periodontium and refers to
inflammatory diseases which are plaque-induced.
These fall into two groups:
• Gingivitis
• Periodontitis
12.1.2.1. Gingivitis
Description
This is an inflammatory condition of the free gingivae. It is caused by dental
plaque and supragingival calculus or tartar. In this condition, there is no
destruction of the supporting tissue.
Clinical features
• Red mucosa
• Loss of gum texture
333
• Gums bleed easily
Treatment
Scaling and prophylaxis
Drugs
• Metronidazole, adults; 200mg orally 3 times daily for 5 days, children;
7.5mg/kg orally 8 hourly for 5 days
• Phenoxymethylpenicillin, adults; 250-500mg orally 6 hourly for 5 days,
children; 12.5 -25mg/kg orally 6 hourly for 5 days or
• Erythromycin, adults; 250-500mg orally 6 hourly for 5 days, children; 28 years; 12.5 - 25mg/kg orally 6 hourly, 8-12 years; 25 – 50mg/kg 6
hourly for 5 days
Preventive
• Encourage maintenance of good oral hygiene
• Gargle warm salty water or mouthwash after every ‹ meal
• Brush teeth at least twice daily
• Flossing
12.1.2.2. Periodontitis
Description
This is an inflammatory response of the free gingivae affecting all the
periodontal structures. It is caused by plaque and supra or subgingival
calculus. It results in the destruction of the attachment apparatus and the
development of a periodontal pocket. Halitosis is usually present.
Treatment
• Scaling and prophylaxis
• Subgingival curettage
Drugs
Metronidazole, 200mg orally 3 times daily for 5 days Refer patient to the next
level
Prevention
• Encourage maintenance of good oral hygiene
• Use of mouthwash containing fluoride
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12.1.3.
Oral candidiasis
Description
This is an infection of the mouth caused by Candida albicans. It is commonly
known as oral thrush. The infection sometimes also affects the pharynx.
The predisposing factors include trauma, denture wearing, dryness of the
mouth, inhaled steroids, radiotherapy, diabetes mellitus, antibiotic therapy,
HIV/AIDS.
Clinical features
• Creamy white or yellow plaques on normal mucosa
• Patches on the palatal and buccal mucosa and dorsum ‰ of the tongue
and gums.
• Removal of plaques reveals bleeding surface.
Treatment
Drugs
• Gentian violet solution, topically 2 times daily for 7 days or
• Nystatin oral suspension or lozenges, 2 times daily for up to 10 days or
• Miconazole oral gel applied 2 times daily for 10 days or
Refer to a specialist in case of:
• No improvement
• Painful or difficulty in swallowing or
• Affected pharynx.
Supportive
• Remove or treat the predisposing factor.
• Use snuggly-fitting dentures.
• Good oral hygiene.
• Gargle warm salty water after every meal.
12.1.4.
Herpes simplex stomatitis
Description
This is inflammation of the mucosal area due to infection by the herpes
simplex virus. It is usually a self-limiting condition clearing up after 7 - 10
days. It is characterised by painful, shallow ulcers around the lip area, gums
and tongue. It is common in small children who usually present with high
fever and refusal of food because it is too painful to eat.
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Treatment
• Debridement
• Mouthwash with tetracycline
Medicines
• Paracetamol, adults; 500-1g orally 3 times daily,
• children; 10-20mg / kg orally 3 times daily for 5 days.
• *Metronidazole, adults; 200-400mg orally 3 times daily, children; 100200mg orally 3 times daily for 5 days or
• *Phenoxymethylpenicillin, adults; 250-500mg orally 4 times daily,
children; 125-250mg orally 4 times daily for 5 days.
*Used in case of secondary infection only.
Supportive
• Increase fluid intake
• In severe cases, a nasogastric tube may be necessary until
• the child can feed again.
• Saline mouthwash and gargle
• Avoid acidic foods and drinks
• Refer to a specialist if the condition is severe or does not heal within 710 days.
12.1.5.
Mouth Ulcers
Description
This is a condition in which there is damage to the mucosal lining of the
mouth, including the tongue. These are similar to ulcers due to the herpes
simplex virus. They are painful and may occur singly or in groups. They
frequently recur and can be very troublesome.
Treatment
• Paracetamol, adults; 500-1g orally 3 times daily, ˆˆ children; 10-20mg/kg
orally 3 times daily
• Aspirin, 600mg orally 3 times daily for adults only
• Chlorhexidine gluconate, 10-15ml as a mouthwash kept in the mouth for
about 30 seconds to 1 minute 2-3 times daily Ulcers that do not heal
rapidly should be referred to a specialist.
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12.2.
PHARYNGEAL DISEASES
These are conditions affecting the pharynx. They include:
• Tonsillitis and pharyngitis
• Peri-tonsillar abscess
• Epiglottitis
12.2.1.
Tonsillitis and Pharyngitis
Description
This is an inflammation of the pharynx and tonsils. There are two types of
pharyngitis; viral and bacterial. The vast majority of pharyngitis is viral,
which is self-limiting. In clinical practice, it is difficult to distinguish between
viral and bacterial pharyngitis. It is important to diagnose and treat
streptococcal throat infections to prevent Rheumatic fever and other
complications.
Acute tonsillitis is most frequent in childhood. However, it is very rare in
adults. Untreated acute tonsillitis will subside over the course of one week.
Appropriate treatment will make the illness shorter.
Diphtheria infection is an important differential diagnosis.
Clinical features
Symptoms
• Sore throat
• Pain on swallowing
• Headache
• Fever
• Voice change
Signs of streptococcal pharyngitis
• High fever
• White pharyngeal exudates
• Tender enlarged anterior cervical lymph nodes
• Grossly enlarged painful tonsils which are asymmetrical
• Absence of signs suggesting viral pharyngitis.
Signs of viral pharyngitis
• Nasal stuffiness
• Coryza
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• Irritating cough
• Conjunctivitis
Signs of tonsillitis:
• Hyperaemic tonsils
• Enlarged tonsils
• Pus in the crypts
Treatment
Viral pharyngitis
• No antibiotics should be given
• Analgesia for pain and fever relief
Streptococcal pharyngitis and tonsillitis
Drugs
• Phenoxymethylpenicillin, adults; 250-500mg orally 6 hourly at least 30
minutes before food, children, up to 1 year; 62.5mg orally 6 hourly, 1-5
years; 125mg orally 6 hourly, 6-12 years; 250mg orally 6 hourly for 7
days or
• Erythromycin, adults; 250mg-500mg orally 6 hourly, children, up to 2
years; 125mg orally 6 hourly, 2-8 years; 250mg orally 6 hourly for 7 days
• Paracetamol, adults; 500mg-1g orally 3-4 times daily, children; 1020mg/kg orally 3-4 times daily Complications of streptococcal
pharyngitis
• Peritonsillar and parapharyngeal abscesses
• Rheumatic fever
Refer for specialist treatment
12.2.2.
Peri-tonsillar abscess
Description
This is an abscess around the tonsils
Clinical features
It presents with signs of acute tonsillitis but with more pain on one side and
almost always a large, very tender lymph node on that side. The patient may
be unable to swallow fluids. It is always difficult to see into the mouth
because the mouth cannot be opened widely. Use a good light and gently
depress the tongue on the painful side to look for bulging of the tonsil and the
palate above the tonsil.
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Treatment
Drugs
• Pethidine (if needed) , adults; 50-100mg intramuscularly repeated 4
hourly, children; 0.5-1mg/kg intramuscularly repeated 4 hourly
• Dextrose solution or Normal Saline intravenously
• Benzyl Penicillin, adults; 1 MU intravenously 6 hourly, children; 50,000100,000 IU kg/day intravenously in 4 divided doses for 5 days or
• Phenoxymethyl penicillin, adults; 500-750 mg orally 6 hourly, children;
20-50 mg/kg orally daily in 4 divided doses for 5 days
• Metronidazole, adults; 500mg intravenously or 400mg orally 8 hourly for
5 days, children; 20-30 mg/kg orally or 7.5 mg/kg intravenously in
divided doses 8 hourly
Surgical
• Incision and drainage, if necessary Patients should be nursed in a place
where surgery can be done urgently.
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12.2.3.
Epiglottitis
Description
This is an acute inflammation of the epiglottis due to Haemophilus influenzae
type B. The condition can be life-threatening.
Clinical features
• Acute onset, usually within 6 hours
• High fever
• Toxic patient
• Drooling of saliva
• Respiratory stridor
Diagnosis
Diagnosis should be suspected from clinical features. Avoid throat
examination as the patient's airway may become completely obstructed.
Treatment
Refer immediately for specialised treatment.
Drugs
• Chloramphenicol, adults; 500mg-1g intravenously 4 times daily,
children; 50-100mg/kg daily in 4 divided doses for 5 days.
• Cefotaxime, adults; 1g intramuscularly/ intravenously 12 hourly,
increased in severe infection to 8 - 12 g in 3-4 divided doses, children;
100-150mg/kg daily in 2-4 divided doses increased up to 200mg/kg daily
in very severe infections.
12.3. NASAL DISEASES
These include:
• Acute sinusitis
• Allergic rhinitis
12.3.1.
Acute sinusitis
Description
This is an inflammation of one or more sinuses. This condition usually occurs
after suffering from a common cold or allergic rhinitis.
Clinical features
• Tenderness over the affected sinuses
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•
•
•
•
Headache
Blocked nose
Copious mucopurulent discharge
Fever
Treatment
Medicines
• Paracetamol, adults; 500mg-1g orally 3-4 times daily, children; 1020mg/kg orally 3-4 times daily
• Amoxicillin, adults; 250 - 500mg orally 3 times daily, children over 20kg;
250mg orally 3 times daily, 10- 20 kg; 125mg orally 3 times daily, below
10kg;
62.5mg orally 3 times daily for 5 days or
• Cotrimoxazole, adults and children over 12 years old; 960mg orally 2
times daily, children 5 - 12 years; 480mg orally 2 times daily, 6 months
to 5 years;
240mg orally 2 times daily
Supportive
• Steam inhalation
• Saline nasal drops
Complications
• Dental abscess
• Periorbital swelling
Patients with complications need referral to a specialist.
12.3.2. Allergic rhinitis
Description
This is inflammation of the nasal mucosa due to hypersensitivity to allergens.
The common allergens include pollen, dust, animals, or food.
Clinical features
• Recurrent nasal blockage
• Irritation
• Watery nasal discharge
• Sneezing
• Watery and itchy eyes
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Treatment
Drugs
• Chlorpheniramine, adults and children over 12 years; 4mg orally 2 times
daily, children 5 - 12 years old; 2mg orally 2 times daily, 6 months to 1
year 1mg orally 2 times daily
• Loratidine, adults; 10mg orally once daily, children 2-5 years; 2-5mg
orally once daily
Supportive
• Saline nasal drops used at night. But these should not be used for too long
periods, as rebound blockage is likely to occur
• Avoid causative allergens
Persistent attacks with severe symptoms should be referred to the specialist.
12.4.
EAR CONDITIONS
These include:
• Acute otitis media
• Chronic suppurative otitis media
12.4.1. Acute otitis media
Description
This is inflammation of the middle ear. It usually follows an upper respiratory
tract infection.
Clinical features
• Fever
• Severe pain in the ear, worse at night
• Babies cry, rub or pull the ear
• Red bulging eardrum
• Blood and/or pus discharge
Treatment
Drugs
• Amoxicillin, adults; 250-500mg orally 8 hourly, children; 12.5-25mg/kg
orally 8 hourly for 5 days
• Aspirin (adults only); 600mg orally 3 times daily
• Paracetamol, adults; 500mg-1g orally 3-4 times daily, children; 1020mg/kg orally 3-4 times daily
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• Phenoxymethyl penicillin, adults; 250-500mg orally 6 hourly, children up
to 1 year; 62.5 orally 6 hourly, 1-5 years; 125mg orally 6 hourly, 6-12
years; 250mg every 6 hours for 7-10 days or
• Erythromycin, adults; 250-500mg orally 4 times daily, children; 125250mg orally 4 times daily for 5 days
Supportive
• Avoid wetting the inside of the ear
Complications
• Mastoiditis
• Hearing loss
• Acquired cholesteatoma
12.4.2.
Chronic suppurative otitis media
This is a condition in which there is an ear discharge lasting more than two
weeks and results from inadequately treating or neglecting acute otitis media.
Clinical features
• Painless discharge from one or both ears
• Perforation of the eardrum
• Discharge may be thin, clear, mucoid to thick, pasty,
• offensive mucopus
• Presence of multiple organism infection
• Red and swollen middle ear mucosa
• Mucosa may bulge if blocked
Treatment
• Wick dry with a cotton cloth
• Keep the ear as dry as possible
• Antibiotics are not usually indicated
• The patient should be referred when:
1. Pain is present
2. There is swelling behind the ear
3. There is poor response to treatment.
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13. SURGICAL CONDITIONS
This chapter discusses the following conditions:
• Injuries
• Animal bites
• Testicular torsion
• Strangulated hernia
• Hydrocele
• Varicocele
13.1. INJURIES
Description
Injuries refer to harm that occurs to the body. They may be intentional or due
to accidents. The cause may be physical, chemical, burns, or traffic accidents.
Injuries may cause temporary or permanent disability. Injuries may be
divided into minor and major injuries.
13.1.1.
Minor injuries
These include cuts and blunt injuries. Cuts are usually from sharp objects,
especially household implements. Blunt injuries usually follow assault.
Clinical features
Cuts may bleed and if seen late may have developed an infection with pus
formation.
Blunt injuries will cause bruises or haematomas or more serious deeper
injuries, such as bone fractures.
Treatment
• Clean open wounds thoroughly with soap and water or a disinfectant
• Remove foreign matter and dead tissue
• Suture fresh superficial wounds
• Do not suture open wounds after 6 hours of injury
• Cover the wound with a dressing
Drugs
• Tetanus toxoid, 0.5ml intramuscularly as a single dose
• Anti-tetanus serum, 250 IU as a single dose (for non-immunised patients)
344
•
Paracetamol, adults; 500mg-1g orally 3 times daily, children; 1020mg/kg orally 3 times daily or
•
Aspirin, (adults only) 600 mg orally 3 times daily Haematomas
usually resolve on their own.
13.1.2.
Major injuries
These are multiple injuries or serious injuries to specific body parts.
13.1.2.1 Multiple injuries
These may be characterised by fractures, bruises, internal injuries, head
injuries, spinal injuries, and chest trauma or eye injuries. The patient will
present with two or more of such injuries. They may result from traffic
accidents, assault or war.
Treatment
Initially, a quick history and examination should be carried out to establish
the severity of the injuries.
• Establish a clear airway
• Remove any debris in the mouth
• Insert airway breathing, if necessary
• Ensure good circulation
Set up an intravenous line with the largest gauge possible
• Control bleeding
• Resuscitate, if necessary
• Treat shock
• Look for signs of internal haemorrhage
• Group and cross match blood
• Clean and debride wounds before suturing
• Immobilize fractures immediately
Drugs
• Tetanus toxoid, 0.5ml intramuscularly as a single dose
Refer the patient to the nearest hospital in case of head or chest injuries,
suspected internal haemorrhage, loss of consciousness or need of additional
care.
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13.1.3.
Specific injuries
13.1.3.1. Head injuries
The patient may present with a laceration, fracture, a history of altered
consciousness or amnesia
General Management
• An accurate history is needed, especially to find out if the patient was
unconscious at any time after the head injury. A careful examination is
needed. Head injuries may be associated with a fracture or dislocation of
the cervical spine
• Brainstem compression causes hypertension and bradycardia, with
irregular respiration
• Assess the conscious level using the Glasgow Coma Scale (GCS). The
face and head should be examined carefully for blood or cerebrospinal
fluid draining from the nose or ears, suggesting a fractured base of the
skull
Examination of the eyes is needed as a unilateral
fixed and dilated pupil may indicate a haematoma on the same side
Investigations
• X-ray of the cervical spine (lateral view)
• X-ray of the skull (anteroposterior, lateral and Townes’ views)
Specific treatment
The patient should be admitted to hospital for observation for at least 24
hours, even if it is a trivial injury, if there is:
• History of loss of consciousness
• Loss of consciousness on arrival in hospital
• Focal neurological signs
• Post-traumatic amnesia
• Significant drowsiness
• Severe headache or vomiting
• Blurred vision
• Other associated injuries
• Skull fracture
Management
• Do hourly observation of GCS, breathing pattern, vital signs, and pupil
reaction
346
• The airway must be safe and patients nursed with the head propped up at
150
• Severe injuries need specialised management by a neurological centre
• Restrict intravenous fluids to minimise cerebral oedema. Sufficient fluid
to maintain a urine output of 0.5 – 1ml/kg/hour should be given
1.1.3.2. Facial injuries
Treatment
• Maintain the airway as swelling may be severe
• Intubation or tracheostomy may be performed, if necessary
• Prophylactic antibiotics should be given for facial fractures
13.1.3.3. Spinal injuries
This should always be suspected in patients with head injury or multiple
trauma(s). There may be numbness, paresthesia, weakness of the limbs or
pain radiating down a limb.
Diagnosis
Lateral view X-ray of the cervical spine, including all cervical vertebrae and
first thoracic vertebra.
Treatment
• The patient should be moved very carefully
• Avoid rotation and extremes of flexion and extension
• The attendants should work as a team to move the patient. One assumes
responsibility for the neck and places the fingers under the angle of the
mandible with palms over the ears and parietal region and maintaining
gentle traction. Keep the neck straight and in line with the body. The neck
can be splinted with a sandbag on either side or a cervical collar
Refer for specialised management, which will be needed for specific injuries.
13.1.3.4. Eye injuries
For penetrating or blunt trauma refer the patient for specialised treatment at a
higher level of care. (See also chapter 9)
13.1.3.5. Chest injuries
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Clinical features
• Pain on breathing
• Dyspnea
• Unequal movement of the chest wall
• Surgical emphysema of neck and chest
• Palpable rib fractures
• Bruising
• Tracheal deviation
• Restlessness
• Central cyanosis
• Tachycardia
• Hypotension
• Sweating
Diagnosis
• Bruising over the lower left ribs may indicate a ruptured spleen
• Bruising over the right lower ribs may indicate a ruptured liver
• Chest X-ray (anteroposterior view)
Treatment
• Rib fractures do not require any specific management apart from
analgesia
• A large flail chest may require mechanical ventilation for 10-14 days and
stronger analgesia
Pneumothorax
There are two types: open and tension.
Open
• Conservative management
• Refer for appropriate treatment if patient’s condition deteriorates Tension
• This is an emergency
• Convert to open pneumothorax by pushing a large-bore needle into the
2nd intercostal space along the midclavicular line
• Insert an intercostal underwater seal drainage
Haemothorax
There are two types: asymptomatic and symptomatic.
348
Asymptomatic
• Conservative management Refer for appropriate treatment if patient’s
condition deteriorates
Symptomatic
• Insert an intercostal underwater seal drainage
• The patient should be referred to a higher level or specialist care
Flail chest
• The patient needs oxygen or mechanical ventilation
• Ribs may need to be fixed.
• Refer to a higher level or specialist care
13.1.3.6. Abdominal injuries
Penetrating injuries are usually due to stab and bullet wounds. The patient
may present with a metal protrusion or disembowelment. The injuries may
result in haemoperitoneum. Haemoperitoneum may be present with pain,
abdominal distension, rigidity or tenderness.
Diagnosis
Peritoneal aspiration for haemoperitoneum should be done
Treatment
All abdominal bullet or stab wounds should be explored by laparotomy
13.1.3.7. Renal injuries
There is usually microscopic or macroscopic hematuria.
Diagnosis
• Abdominal ultrasound
• Intravenous urogram
Clinical features
• Swelling in the loin area
• Bruising in the loin area
• Tenderness in the loin area
Treatment
• Catheterise patient
Refer the patient to a specialist for specific treatment
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13.1.3.8. Burns
Description:
A burn is an injury occurring after exposure of the body surface to friction,
chemicals, electricity or extreme temperature.
Clinical Features:
Burns may result in damage to the dermis. Such damage may be partial or fullthickness.
Partial-thickness burns
• Some of the dermis is alive
• Heals in 10-14 days without scarring
• Blisters may be present
• Pain
• Shock may be present
Full-thickness burns
• Damage to all of the dermis
• Usually, heal after 21 days with scarring
• Painless
• Shock may be present
Complications
• Infection
• Anaemia
• Contractures
• Pulmonary oedema may occur after inhalation of smoke
• Acute peptic ulcers
• Acute renal failure
Management
Assessment
• Examine for shock and loss of fluids
• Assess the extent and depth of the burn
• Look for signs of infection
Treatment
Drugs
• Paracetamol, adults; 500mg-1g orally 3 times daily, children; 10-20mg/kg
orally 3 times daily or
350
• Pethidine, 0.5-1mg/kg intramuscularly 4-6 hourly for severe burns
• Tetanus toxoid 0.5ml intramuscularly as a single dose, if necessary
• Topical antibacterial agents – silver nitrate, and silver sulphadiazine cream.
Others used are Povidone-iodine, Chlorhexidine.
Supportive
• High calorie, high proteins diet
• Physiotherapy for burns affecting joints as soon as the patient is resuscitated
and pain has been controlled Specific Care
• Superficial burns should be cleaned with water, dried and left open
• Fluid replacement. Suggested fluids are normal saline, ringer’s lactate or
Hartmann’s solution. 50ml of 50% dextrose per litre can be added
• Do not open blisters
• Dress burns with Vaseline gauze but exposure method is preferred
• Wash burns every 4-6 hours with saltwater
• Use showers. Avoid baths which may allow cross infection
• Slough is removed using wet to dry dressings
• Dressings should not be allowed to dry and stick
• Specific areas such as the eyes, eyelids, ears, perineum and hands need
specific care
• The haemoglobin should be checked once a week and transfusion given, if
necessary
• Monitor urine output. It should be at least 1ml/kg/hour
All patients with deep and extensive burns should be referred to a specialist.
351
Determination of burn size
The burn size in adults is determined using the rule of nines in which the
following body areas are taken to represent 9% or 18%:
Whole of
= 9%
each
=
upper
18%
limb
=18%
Whole of
=18%
each
=9%
lower
limb
Front of
trunk
Back of
trunk
Whole of
head and
neck
Perineum
=1%
The above formula is not applicable to children. In children, the burn size can
be determined by considering the area of one palm surface of the patient’s
hand as 1% of body surface area. This palm surface formula is also applicable
to adults.
Fluid therapy in burns
Fluid requirements
a)
Maintenance requirements are indicated in table below:
352
Age group
Weight (kg)
ml/kg/
24hours
ml/kg
/hour
Neonates
(<3months)
3
150
6
3-10
120
10-20
80
5
3
>20
60
2.5
35
1.5
Infants
(>3months)
Children
Adults
b)Extra requirements
Age under 6
One ration = 2 x burn size x weight
Age 6 or over
One ration = 1 x burn size x weight
Note:
On top of the maintenance fluid requirement which is given at a constant rate,
one ration of extra fluid is given during the first 8 hours from the time of the
burn, a second ration during the next 8 hours and a third ration during the next
24 hours.
Prevention of injuries
• Public education on the supervision of young children
• Household chemicals, insecticides, sharp objects should be kept out of
reach of children.
• Teach road safety measures at an early age
• Safety standards in places of work should be maintained
13.2. BITES
Description
These are bites which are inflicted by animals or humans.
Clinical features
353
A wound may sometimes be associated with fractures or amputations if inflicted
by large animals. There may be bleeding.
Complications
Infection with both aerobic and anaerobic bacteria or viruses.
Treatment
• Clean, debride the wound
• Excise dead tissue
• Leave the wound open for delayed primary or secondary suture
Drugs
• Phenoxymethylpenicillin, adults; 250 -500mg orally 4 times daily, children;
125-250mg orally 4 times daily for 5 days
• Metronidazole, adults; 200-400mg orally 3 times daily, children; 100mg 200mg orally 3 times daily for 5 days
• Tetanus toxoid, 0.5ml intramuscularly as a single dose.
If the bite is from a suspected rabid animal, administer post-exposure rabies
treatment. (Refer to Chapter 2.7).
13.3.
TESTICULAR TORSION
Description
This is the twisting of the testis along its vertical axis, resulting in compromised
blood supply to the testis and the adjoining spermatic cord. It may be
spontaneous or following strenuous activity. It may also result from anomalies
in the development of the tunica vaginalis and the spermatic cord.
Clinical Features
Symptoms
• Severe local pain
• Nausea
• Vomiting
• Scrotal swelling
• Dark discolouration of the scrotum
• Fever
Diagnosis
354
This is clinical and confirmed on surgical exploration
Treatment
• Immediate surgical intervention is advised if the torsion is suspected.
Surgical exploration of the scrotum within a few hours offers the only hope
of testicular salvage.
• Fixation of the contralateral testis is performed to prevent torsion on that
side.
• Appropriate antibiotic cover is required.
13.4.
STRANGULATED HERNIA
Description
This is a condition in which the blood flow to an abnormally protruding viscus
is compromised. The strangulation can occur in any type of hernia.
Clinical Features
• Abdominal pain
• Fever
• Vomiting
• Irritability
• Restlessness
• Abdominal distension
• Guarding of the abdomen
• Rebound tenderness
Hernia must be differentiated from hydrocele, in the former, the examiner
cannot palpate the cord above the mass, whereas with hydrocele normal cord
structures are usually palpable above the mass. In strangulated hernia, there is
a previous history of a swelling. A hydrocele is often cystic and can be
trans-illuminated using a torch.
Diagnosis
• History and examination is very important in making a diagnosis
• Abdominal X-rays
Treatment
The basic line of management is immediate surgical intervention and relieving
the obstruction. It is mandatory to inspect the bowel if gangrenous resection is
done and anastomose the viable segments.
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Drugs
• Benzylpenicillin, adults; 2 MU intravenously 4 times daily, children;
50,000-100,000 IU/kg intravenously in 4 divided doses for 5 days
• Metronidazole, adults; 500mg intravenously 3 times daily, children; 7.
5mg/kg 8 hourly for 5 days
• Gentamicin, adults; 80mg intravenously 3 times daily, children; 2-3mg/kg
intravenously in three divided doses for 5 days
• Intravenous fluids
13.5
HYDROCELE
Description
This is a condition characterised by the accumulation of fluid in the tunica
vaginalis and it presents as a cystic scrotal mass.
Clinical Features
• Intrinsic, often cystic and painless scrotal mass
• May be painful when severely distended
• Mass is unilateral
• Transluminal mass
• Spermatic cord is palpable above the cystic mass
Treatment
• Hydrocelectomy
• Appropriate antibiotic cover is required
13.6.
VARICOCELE
Description
This is a collection of large veins, usually occurring in the left scrotum. It feels
like a “bag of worms”. It is present when the patient is in the upright position
and should empty in the supine position.
Clinical Features
• Pain
• Feeling of scrotal fullness
Treatment
• Varicocelectomy
• Appropriate antibiotics cover is required
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13.7. TESTICULAR TUMOURS
Description
These are malignant growths arising from the testis. Testicular tumours account for the
majority of solid malignancies in males older than 30 years of age.
Pathology
Most malignant testicular tumours arise from the primordial germ cell and are
classified as seminoma teratoma, embryonal carcinoma, teratocarcinoma and
choriocarcinoma in order of increasing malignancy.
Clinical Features
The usual presenting sign is a scrotal mass, increasingly progressive in size and
sometimes associated with pain. Many patients relate the mass to minor trauma
indicating the time when the mass, was first discovered. Haemorrhage into a rapidly
expanding tumour may produce exquisite local pain and tenderness. A firm mass
arising from the testis is cause for immediate clinical suspicion of testicular tumour.
Diagnosis
• Physical examination
• Ultrasound may localise the lesion to the testis.
• Exploration, exposing and clamping the cord through an inguinal incision before
mobilizing the tumour.
• Chest x-ray and IVU is done to rule out metastasis.
• Prognosis depends on the histological finding and the extent of the tumour.
Treatment
Inguinal orchidectomy must be performed and transabdominal retroperitoneal
lymph node dissection is usually recommended for terato and embryonal carcinoma
and adult teratoma.
Irradiation may be effective in seminoma, using 30 to 50ay (3000 to 5000 rads) to
abdominal and mediastinal lymphatics as well as left supraclavicular areas, depending
on the staging.
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13.8. ACUTE MUMPS ORCHITIS
Description
This is an inflammatory condition of the testis caused by the mumps virus. It is a
paramyxovirus. About 20 % of post-pubertal male patients have testicular
inflammation, usually unilateral.
Clinical Features
There is testicular swelling associated with inflammation in other organs - parotid
gland, pancreas, meninges, etc. Testicular atrophy may ensue.
Treatment
This is symptomatic - analgesics may be used for pain and generalised malaise.
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14.
POISONING
Description
This is the exposure by ingestion, inhalation or other means of a substance
capable of causing harm to the body.
Clinical features
The patient may present a variety of symptoms ranging from mild to serious
ones like the loss of consciousness.
Diagnosis
• Assess for vital signs
• Ascertain as far as possible, the nature and quantity of the poison and when
it was taken.
14.1.
MANAGEMENT OF A POISONED PATIENT
Management depends on the type of poison taken and the clinical condition of
the patient. Treatment is aimed at slowing down, reducing or preventing further
absorption of the poison and to counteract the effects of the poison already
absorbed.
All patients with poisoning should be referred to a specialist after emergency
treatment.
Emergency resuscitation measures should be taken in the following
circumstances:
a)Obstructed airway
• Pull the tongue forward
• Remove dentures, foreign bodies (e.g. food) and oral secretions
• Hold the jaw forward and insert an oropharyngeal airway if possible
• Put the patient in a semi-prone position with head down to minimise the
risk of inhaling vomit.
b) Inadequate respiration
• Give continuous oxygen
• Apply assisted ventilation with an Ambu bag or mouth to mouth or intubate
and do mouth to tube respiration.
• Do not use respiratory stimulants as they cause harm.
c) Hypotension
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• Keep patient in a position with his head downwards by elevating the foot of
the bed
• Administer 0.9% sodium chloride intravenously.
d) Recurrent fits
Control with diazepam, adults; 5-10mg intravenously stat, children; 0.20.3mg/kg intravenously stat.
Repeat as necessary.
e) Removal of poison from the stomach
Gastric emptying carries the risk of the victim inhaling gastric contents. The
benefit of the procedure should therefore be weighed against this risk. The
procedure should not be performed in the following circumstances:
• When corrosive substances (e.g. acids, alkalis and petroleum products)
have been swallowed.
• When there is marked hypothermia (less than 30 0C)
• When the amount of poison swallowed is minimal
• If the poison was ingested more than 2 hours earlier (except in the case of
poisoning with salicylates, tricyclic anti-depressants and beta-blockers)
Procedure
To remove the poison from the stomach, two methods may be used:
• Inducing vomiting by giving:
–Ipecacuanha syrup, adults; 30ml, children above
1 year; 15ml, children below 1 year;
10ml followed by a glass of water. Repeat after 20 minutes if necessary.
• Gastric lavage
If done in an unconscious patient, a cuffed endotracheal tube should be passed
to prevent aspiration of stomach contents into the lungs. Reduction of
absorption of the poison
After vomiting has occurred:
• Activated charcoal; 50g mixed with 400ml water in a bottle and shaken
well. Administer the suspension in a dose of 5ml/kg. Repeat every 4 hours.
Total dose of 100g for adults, if necessary
• Magnesium sulphate mixture or magnesium hydroxide mixture; 50ml to
avoid constipation
• Milk, cooking oil or beaten raw egg may also be given in the absence of
activated charcoal, to delay the absorption of the poison
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14.2.
TREATMENT OF SPECIFIC COMMON POISONING
14.2.1.
Aspirin and other Salicylates
Treatment
• Induce emesis with ipecacuanha, unless respiration is depressed
• Give activated charcoal
• If respiration is depressed, do airway-protected gastric lavage
• Gastric emptying is effective up to 4 hours after ingestion of poison
14.2.2.
Carbon monoxide
Treatment
• Remove the patient from further exposure
• Give oxygen for several hours
• Maintain blood pressure and normal body temperature
• To reduce cerebral oedema, give 20% mannitol, intravenously 5ml/kg body
weight over 20 minutes and a corticosteroid intravenously or
intramuscularly 4 hourly (e.g. prednisolone, 1mg/kg body weight
dexamethasone, 0.15mg/kg body weight or hydrocortisone, 4mg/kg body
weight)
• Control convulsions or hyperactivity with diazepam, 0.1mg/kg body weight
by slow intravenous or per rectum
14.2.3.
Ethanol
Treatment
• Remove unabsorbed ethanol by gastric lavage or inducing emesis with
ipecacuanha syrup
• Give activated charcoal
• Maintain adequate airway
• Maintain normal body temperature
• If the patient is hypoglycemic give dextrose 50%, followed by 5%
intravenously
• May need Vitamin B compound, if chronic alcohol abuser
14.2.4.
Insecticides
14.2.4.1. Organochlorine
Treatment
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• Remove the patient from the source of poisoning and remove contaminated
clothing
• Give ipecacuanha syrup
• After vomiting give activated charcoal followed by gastric lavage with 2 –
4 litres water (adult dose)
• Give a laxative such as magnesium hydroxide
• Do not give milk, fats or oils as they will increase absorption of the poison
• Scrub the skin with soap and cold water to remove skin contamination
• Give artificial respiration with oxygen if there is respiratory depression
• Give diazepam, 10mg slow intravenous or phenobarbitone, 100mg
intramuscularly to control convulsions, hyperactivity or tremors
14.2.4.2. Organophosphates and Carbamates
Treatment
• Remove the patient from the source of poisoning and remove contaminated
clothing
• Establish airway and give artificial respiration if necessary
• Remove excess bronchial secretions by suction
• Give ipecacuanha syrup or start gastric lavage
• Give atropine, adults; 2mg intravenously/ intramuscularly stat, children;
100-200mcg intravenously/intramuscularly/orally every 3 – 8 minutes until
signs of atropinisation appear (hot dry skin, dry mouth, widely dilated
pupils and fast pulse)
14.2.5.
Paraffin, petrol and other petroleum products
Treatment
• Prevent the substance from entering the lungs to avoid damage to tissue
• Do not induce vomiting
• Do not do gastric lavage
• Look out for pulmonary oedema and chemical pneumonitis and treat
accordingly.
14.2.6.
Paracetamol poisoning
Clinical features
Liver damage may result in paracetamol overdosage. The damage occurs within
a few hours of ingestion.
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Treatment
• Keep the patient quiet and warm
• Induce emesis with ipecacuanha syrup
• Where there is depressed respiration use airway- protected gastric lavage
• N-acetylcysteine 20% solution, orally 140mg/kg as a loading dose,
followed by 70mg/kg every 4 hours for 3 days. It may be necessary to
administer through a nasogastric tube
• Dextrose 5% intravenously for the first 48 hours
• Phytomenadione 1– 10mg intramuscularly if the prothrombin time ratio
exceeds 2.0
• Do not force diuresis.
14.2.7.
Chloroquine poisoning
Clinical features
Characterised by blurred vision, tinnitus, weakness, hemoglobinuria, oliguria,
low blood pressure, shock, convulsions, cardiac arrest
Treatment
• Induce emesis
• Stomach wash (air-way protected gastric lavage, if respiration is depressed)
• Give activated charcoal
• Treat symptomatically
14.2.8.
Mushroom or other food poisoning
Clinical Features
There will be abdominal pain, nausea, vomiting, and diarrhoea.
Shock, in severe cases
Treatment
Symptomatic:
• Bed rest
• Keep patient warm
• Stomach wash using normal saline
• Give Oral Rehydration Salts (ORS) or intravenous fluids to re-hydrate
• If no improvement, refer to a specialist.
14.2.9.
Snake Bites
Treat all snakebites as an emergency.
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Clinical features
• Pain
• Swelling
• Tissue necrosis
• Regional lymph node swelling
• Haemorrhagic symptoms; bleeding at wounds site
• And other parts of the body
Danger signs
• Drowsiness
• Slurred speech
• Excessive oral secretions
• Difficulty in breathing
• Neurological signs
Treatment
• Immobilise limb and keep slightly elevated
• Administer tetanus toxoid
• Dextrose 5% in saline intravenously
• Treat shock
• Vitamin K, 1-10mg intramuscularly
• Anti-snake venom, if available
• Transfer the patient to a specialist
Prevention
• Wear protective shoes
• Clear bushes near dwelling places
• Avoid walking on dark paths.
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15.
DISORDERS OF THE RENAL SYSTEM
15.1.
METABOLIC DISORDERS
15.1.1. Hyperkalemia
Description
This is serum Potassium > 5.5mmol/L.
Clinical features
Symptoms
Muscle weakness
Signs
• Ascending paralysis with respiratory failure
• Cardiac instability, ventricular fibrillation, cardiac arrest
• May have signs of acute kidney injury or metabolic acidosis
Investigations
• Serum Potassium
• ECG – tall, peaked symmetrical T wave, flat P, increased PR interval, wide
QRS, bradycardia, AV block
Therapy
• Stop the source of Potassium (oranges, bananas, ACEI, K+ sparing
diuretics, cotrimoxazole, heparin, NSAIDs, B-blockers)
1. Severe Hyperkalemia (K > 6.5) and ECG changes
a) Protect the heart- 10mls 10% Calcium Gluconate over 10mins.
b) Push potassium into the cell with insulin, salbutamol (albuterol) and sodium
bicarbonate, either singly or in combination with;
i. 150mmols of 8.4% NaHCO3 in 1 litre 5% Dextrose over 3 to 4 hours if the
patient is also acidotic. Another dose can be given to bring the serum
bicarbonate level to 24 mmol/L.
(DONT USE or INFUSE WITH Ringer’s Lactate but USE 5% Dextrose for
infusion).
ii. 100mls 50% Dextrose with 10 IU soluble insulin over 15-20mins. May give
2-4 hourly as required. Monitor serum glucose 2-4 hourly.
iii. 10-20mg nebulised salbutamol
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c. Remove potassium from the body with the following;
i. Frusemide 1mg/kg IV (Please hydrate patient first if dehydrated)
ii. Kayexalate/Sodium Resonium 15-30g in 50- 100mls 20% Sorbitol or with
lactulose PO/PR
iii. Consider Hemodialysis if refractory
2. Moderate Hyperkalemia (Potassium 6.0 – 6.5 mmol/L)
a. Push Potassium (K+) into the cell
b. Push Potassium (K+) out of the body
3. Mild Hyperkalemia (Potassium 5.5 – 5.9 mmol/L) Push Potassium (K+) out
of the body
15.1.2.
Hypokalemia
Description
Serum Potassium (K+) < 3.5, may be associated with hypomagnesaemia and
hypocalcaemia.
Clinical features
Symptoms
Muscle weakness, fatigue, constipation, muscle cramps.
Signs
Paralytic ileus, ascending paralysis, reduced reflexes.
Tetany when associated with alkalosis
• Arrhythmias
Causes
• GIT and Renal losses
Management
Investigations
• Check K+, other electrolytes and serum pH
• ECG- flat or inverted T wave, prominent U wave.
Therapy
• 20mmol KCL in 250-500mls Normal saline over one hour. Check K+ before
repeating dose and ECG monitoring.
• Consider 6-12mls (5-10mml/l) 20% magnesium sulphate or 2mls 50%
magnesium sulphate diluted in 50mls 5% Dextrose over one hour.
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• If cardiac arrhythmia or arrest give 2mmol KCl per minute iv for 5mins.
Repeat ONCE only if necessary
• Oral K+ supplements if K+>3.0
15.1.3.
Hypernatremia
Description serum Na+ less than 150mmol/ L
Clinical features
Symptoms
• thirsty, nausea, vomiting, weakness, malaise
• muscle tremor, weakness
Signs
Drowsiness, stupor, coma, convulsions, tremors, ataxia
Causes
• water loss more than electrolyte
–GIT losses,
–Renal losses (osmotic diuresis, DI)
• increase in Na+
–Hyperaldosteronism, Cushing’s
–Excessive saline or sodium bicarbonate infusion
Management
• Investigate and treat the cause
• Please do urine Na+ as well
Therapy
• Correct water deficit – rehydrate first if the patient is dehydrated
• Stable/asymptomatic patients
–take it easy
–replace fluids orally
• unstable/symptomatic patients
–IV fluids with NS, DNS, avoid 5%Dextrose as Na+ may drop too fast
–rate of lowering serum Na+ 0.5-1mmol/hr, aim for 12mmol/l in 24hrs and not
more than this
–ESTIMATE THE EFFECT OF 1 LITRE OF ANY INFUSATE ON SERUM
Na+
–Change in serum Na+ = ( infusate Na+ - Serum Na+) divided by (total body
water + 1)
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–The answer is in mmol/L. The formula helps to calculate the infusion rate so
that you do not exceed 1 mmol/min.
15.1.4.
Hyponatremia
Description
Low serum Na but treatment warranted with severe
(<120mmol/l) or acute.
Clinical features
• asymptomatic unless severe or acute
• nausea, vomiting, seizures, coma
Causes
• hypovolemic
• GI losses, renal losses
Euvolemic
• SIADH
• Hypothyroidism
• Adrenal insufficiency
Hypovolemic
• CCF
• cirrhosis
• Nephrotic syndrome
Management
• Investigate and treat the cause.
• Urine Na+ should be ordered, urine and serum osmolarity should be
measured.
Therapy
• CNS manifestations
–200mls 5% NaCl over 6 hours. Monitor serum Na+ hourly
–Aim to increase Na+ to 120mmol/l at a rate of
0.5 – 1.0mmol/l per hour
–If no CNS symptoms, do not use Hypertonic saline.
–Once serum sodium is around 120mmol/l, stop active therapy and restrict fluid
intake to approx.
500mls/day.
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• Asymptomatic
–Use of conservative measures such as fluid restriction may be enough.
• SIADH
–restrict fluid intake to 50-60% of estimated maintenance
requirements(±1L/day).
fluid
15.1.5. Hypercalcaemia
Description
Corrected serum Ca 2+ > 2.65mmol/L.
Clinical features
Symptoms
• Polyuria, polydipsia, dysphagia, bone pain, renal colic
• Muscle weakness
Signs
• Confusion, hypotonia, dysarthria, coma, seizures
Causes
Hyperparathyroidism, malignancy, sarcoidosis, drugs,
Vitamin D intoxication especially in renal patients
Investigations
• ECG- short QT interval, wide QRS complex, flat T, AV block, may have fatal
arrhythmias
• Serum Calcium U+Es, albumin, Magnesium, Phosphate, ALP, Serum
electrophoresis
• PTH
• X-RAYS
Frequent association with hypokalemia increasing risk of arrhythmias.
Therapy
• Hydrate with Normal Saline 500mls/hr until Urine out > 200mls/hr then
reduce 100-200mls per hour.
• Furosemide 1mg/kg only when the patient has been hydrated or if in cardiac
failure
• Hemodialysis or peritoneal Dialysis with low Calcium dialysate.
Hemodialysis preferred.
• Prednisolone 40mg daily especially for Vitamin D intoxication, sarcoidosis,
multiple myeloma, metastasis
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• Pamidronate 60-90mg in 500-1000mls Normal Saline infusion over 4-6hrs.
should be effective within 48hrs Monitor and replace K+ and Mg2+.
15.4.
CATHETER-RELATED BLOODSTREAM INFECTIONS
(CRBSI)
Intravenous catheters inserted into central veins such as the internal jugular
vein, subclavian vein or femoral vein provide the only and vital access for
hemodialysis for patients with no arterio-venous fistulas. Introduction of
catheters including venous and urinary catheters increases the risk of
bloodstream infections.
In most cases CRBSI can be prevented by simple interventions:
• Hand hygiene
• Using full barrier precautions during the insertion of central venous
catheters,
• Cleaning the skin with chlorhexidine,
• Avoiding the femoral site if possible
• Removing unnecessary catheters including urinary catheters as soon as
possible
Management of CRBSI
Patients with central venous accesses and new fevers should be evaluated for
CRBSI, with the catheter as the source of the infection unless otherwise
excluded by patient examination and investigations. The following minimum
evaluations should be done.
• Thorough patient history and examination including the central line
insertion sites to assess for superficial thrombophlebitis and insertion site
abscess
• Two sets of blood cultures obtained from two different sites and another
drawn from the central venous access site
• If you suspect bacteremia/sepsis remove catheters and culture the tip to
guide antibiotic treatment required.
Other investigations as determined from history and physical examination
of the patient
• Empiric antibiotics guided by local microbiology and susceptibility of
organisms
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• Vancomycin 1gm IV stat dose and thereafter dosed according to renal
function for empiric treatment of Methicillin-Resistant Staphylococcus
aureus, Coagulase-Negative Staph, Enterococci species
• For patients unable to tolerate Vancomycin due to deteriorating renal
function, switch to Linezolid for the treatment of MRSA and resistant
Enterococcus
• Fourth Generation Cephalosporins (Cefepime 2gm IV Stat) or
Carbapenems (Doripenem or Meropenem) should be initiated for empiric
gram-negative bacteremia such as Pseudomonas that may be resistant to
routinely used gram-negative antibiotics.
• If cultures are positive for fungal elements particularly Candida albicans,
initiate Caspofungin until sensitivity results are available and switch to
Fluconazole if susceptible. Remove the central line immediately in the case
of candidemia.
15.5. GLOMERULAR DISORDERS
Five clinical syndromes
• Nephrotic syndrome
• Nephritic syndrome
• Rapid progressive glomerulonephritis
• Asymptomatic Hematuria or and proteinuria
• Chronic glomerulonephritis
15.5.1. Nephrotic syndrome
Description
• At least 3.5g proteinuria in 24hrs Generalised oedema
Low serum albumin
Hypercholesterinemia
Causes
• Minimal change disease
• Membranous
- Focal segmental glomerulosclerosis (FSGS)
- Membranoproliferative glomerulonephritis (MPGN)
• Lupus Nephritis
• Diabetic nephropathy
• Amyloidosis
Clinical features
371
Symptoms
• Facial swelling worse in the morning
• Frothy urine
Signs
• Oedema
• Usually normal BP
• Urine dipstick >2 + proteinuria, hematuria rare except in FSGS
Diagnosis
• Renal biopsy needed for light microscopy, immunofluorescence (IF) and
electron microscopy (EM)
• Thus early referral to Nephrologist important
General Management
• Salt restriction
• No need for protein restriction in our setting
• Furosemide 80-120mg/day (aim 0.5-1L/day)
• Proteinuria lowering drugs
–Titrate dose depending on proteinuria
–ACEI: - Enalapril 2.5 – 20mg/day or Perindopril 4-16mg daily
–ARB: - Losartan 25-100mg/day or Micardis 40-160mg/day.
• Lipid-lowering
–Simvastatin 10-40mg daily or atorvastatin 10-20mg daily
• Anti-coagulation (INR 2-3)
–Only if albumin < 20g/l, bedridden, very rapid diuresis, otherwise do not use
routinely
–Warfarin daily
Pathological classification
a) Minimal change disease (MCD)
Description
Pathologically no glomerular changes on light microscopy but podocytes are
effaced on electron microscopy Presents with nephrotic syndrome
Causes
• Idiopathic
• Secondary; NSAIDS, bee sting, lymphomas
Therapy
Idiopathic MCD
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• ACEI/ARB are not used initially in MCD
• Prednisone, 1 mg/kg daily or 2 mg/kg QOD in the morning for a minimum of
8 weeks. (If the response is after 8 weeks, treat for another 2 weeks after
response)
• Taper 5 mg/day every 3-4 days to 30, then use QOD, taper 5 mg/dose/week
to 0.
• If relapse while tapering (steroid dependent) retreat with 4-week course.
• If relapse off steroids, retreat with 4-week course.
• If the patient remains steroid-dependent or has > 3 relapses/year can use low
dose prednisone (10-15 mg) for a year to maintain remission,
• If using more than 0.3-0.4 mg/day of prednisone long term, treat with
cyclophosphamide 2 mg/kg PO for 12 weeks.
Steroid resistance is usually defined as no response
after 16weeks of 1 mg/kg.
b)
Membranous
Pathologically immune deposits are visible just above or within the glomerular
basement membrane Presents with nephrotic syndrome
Immune Causes
• Idiopathic – 80%
• Infections -HBV, HCV, syphilis, schistosomiasis, malaria
• Drugs- penicillamine, NSAIDS, Captopril, Gold
• Malignancies- lung, breast, thyroid, GI
• Autoimmune: - SLE, Thyroid disease
Management
Membranous nephropathy: Approach to therapy based on the risk of progression
(6-month observation)
Feature/risk
risk
Urine
protein
GFR
(onset)
GFR (6
months)
Risk
ESRD
(10
years)
Low risk
Medium risk
High
<4
>4 but <8
>8
Normal
Normal
Normal or
low
Stable
or
declining
66-80%
Stable
Stable
< 10%
55%
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Therapy
Conservative,
ACEI/ARB
Steroids,
MMF***
CTX*, CSA**
Steroids,
CSA**,
MMF***
CTX* - cyclophosphamide, CSA** - cyclosporine, MMF*** Mycophenolate
• Prednisone (0.5 mg/kg/day) and Cyclophosphamide
(1.5-2.0 mg/kg/day) po for 6 months OR Cyclosporine 3.5 ng/ml for 12-24
months (keep levels 110-170 ng/ml (or FK .05 mg/kg in bid dose to level 3-5
mg/L) (plus prednisone 0.15 mg/kg to max 15mg)
• Prophylaxis
–INH 300mg od po
–Co-trimoxazole (single dose) 2 tab OD PO
–Fluconazole 100-200mg OD PO
–At least for 3 months
IF NO RESPONSE IN 6 MONTHS
• Methylprednisone 1.1g IV x 3 and then Prednisolone
0.5 mg/kg x 27 days; Chlorambucil 0.2 mg/kg (or Cyclophosphamide, 2 mg/kg)
daily x 30 days.
• Alternate these monthly for 6 months. Do not initiate immunosuppression if
sepsis suspected or present.
• Do not initiate immunosuppression if sepsis suspected or present
a) Focal Segmental Glomerulosclerosis (FSGS)
Description
Pathologically < 50% of all glomeruli affected and of the affected glomeruli, <
50% of their tuft is affected. Presents commonly with Nephrotic syndrome,
asymptomatic hematuria and proteinuria
Causes
• Idiopathic
• Collapsing (HIV), collapsing (non-HIV)
• Low birth weight. prematurity
• Obesity
• Sickle cell anaemia,
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• Anabolic steroids, Heroin, Lithium, pamidronate
Therapy
• General measures for Nephrotic syndrome
Idiopathic FSGS
• Conservative therapy (ACEI/ARB/aldosterone blocker)
• Exclude secondary causes
• Prednisone, 1 mg/kg daily (or 2 mg/kg alt days) for 12-16 weeks (20% CPR
at 8 weeks, 50% at 16weeks)
• May go to 6 months if no steroid contraindication and/or bad prognostic signs
are present.
• If clinical remission (CR) continue for 2 weeks and taper over 2-3 months
using QOD regimen. If urine protein increases to >2.0 gm/day, start CSA.
• If no response at all by 16 weeks, taper and start CSA.
• Steroid resistance is usually defined as no response after 4 months of 1 mg/kg
prednisone.
• If the disease is non-immunologic such as genetic, drug-induced or viral, use
only low dose steroids (0.15 mg/kg) with a calcineurin inhibitor).
Guidelines for use of cyclosporine
• Do not use if GFR <40ml/min or severe interstitial or vascular disease on
biopsy.
• Use 3-5 mg/kg in divided doses and monitor trough levels (100-200 ng/ml).
• Use concomitant low dose prednisone (0.15 mg/kg, maximum 15mg) until
remission.
• Treat for 6 months after a CR or 12 months after a Partial Remission (PR)
occurs and taper slowly over several months. The relapse rate is determined
by the duration of therapy.
• Tacrolimus is an alternative to cyclosporine
Indications for use of Cyclosporine
• Steroids are contra-indicated
• Proteinuria does not diminish by 50% or more after 4 months of steroids.
• Patient is steroid-dependent
• Relapse in < 1 year after CR or PR
• There is a significant increase in proteinuria during steroid taper after CR or
PR
• GFR must be >40 ml/min and interstitial/ vascular disease on biopsy minimal
• The cause of FGS is not immunologic
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FSGS due to HIVAN
• General measures
• cART
• May add prednisolone after six months if the maximum dose of ACEI reached
but still proteinuric.
b)MPGN
Description
Glomerular disease with subendothelial immune deposits forming a double
basement membrane or a dense basement membrane
Causes
• Idiopathic
• HCV, HBV, Infective endocarditis, Shunts, abdominopelvic sepsis
Clinical features
• Nephrotic syndrome – see Description above
• Nephritic syndrome – see Description below
Therapy
• General measures for the treatment of Nephrotic syndrome
• Treat secondary cause
c)
LUPUS Nephritis
Description
Glomerular disease as a result of chronic autoimmune, multisystem,
inflammatory connective tissue disorder of unknown cause (SLE)
Clinical presentation
• Nephrotic syndrome – see Description above
• Nephritic syndrome – see Description below
• Rapid progressive glomerulonephritis – see Description below
• Asymptomatic proteinuria or and hematuria
• Proteinuria or hematuria without any other renal symptoms
• Chronic glomerulonephritis
• Disease with irreversible damage to the kidney. GFR will not improve despite
intervention but may delay further drop in GFR
Diagnosis
• Should meet criteria for the diagnosis of Lupus and look for systemic features;
CNS (psychosis, fits), Cardiac
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(pericarditis), Respiratory (pleuritis), hematologic (Thrombotic microangiopathy,
leukopenia), rheumatologic (arthritis), dermatologic (malar rash, discoid rash,
photosensitivity, mucosal ulcers) renal( hematuria, proteinuria) immunologic
(low C3/C4), GIT (serositis), ANA, ds DNA, anti-Sm
• Should have 4 of the 11 manifestations
• Biopsy needed for LUPUS as histological diagnosis defines treatment
Therapy
• Depends on histological staging (stage 1-6)
• 1 and 2 do not need immunosuppression
–Stage 2 may need treatment if 24hr protein >1g. then give prednisolone 2040mg/day for 1
-3months and taper to 5-10mg/day
• Stage 5 follow guidelines for membranous nephropathy.
• Stage 6 damage already done and do not need active immunosuppression but
follow measures for the management of CKD.
Stage 3 and stage 4
• Induction phase treatment for 24 weeks with:
–Mycophenolate Mofetil (MMF) 1- 1.5g bd or
–IV Cyclophosphamide 0.5-1.0g/m2 monthly
–Plus oral prednisolone 60mg/day (1mg/kg) with taper
–Do not initiate immunosuppression if sepsis suspected or present.
• Prophylaxis
–INH 300mg od PO
–Co-trimoxazole (single dose) 2 tab od PO
–Fluconazole 100-200mg od PO. Give at least for 3months
• Maintenance up to at least 18 months
–MMF 1 – 1.5g bd PO or
– Azathioprine 1-3mg/kg/day po
– IV cyclophosphamide 0.5-1.0g/m2 every 3 months
– Plus prednisolone 5-10mg/day
d)Diabetic Nephropathy
Description
Persistent microalbuminuria or proteinuria on albustix or dipstick respectively
and or urine albumin: creatinine ratio. Persistent means tests should be done three
months apart.
Clinical presentation
377
Symptoms
• Asymptomatic proteinuria, microalbuminuria
• Body swelling
Signs
• No clinical signs on general examination
• Pedal Edema, facial puffiness
• Presence of Diabetic neuropathy and retinopathy makes the diagnosis of
nephropathy more likely
• Classical presentation of diabetic nephropathy does not require renal biopsy
but atypical presentation need a renal biopsy. These include:
–Rapid drop in GFR over a few days to weeks
–Diabetic with hematuria
–Proteinuria in presence of HIV, Hepatitis B, SLE, small vessel vasculitis (ANCA
positive)
Management
• General Measures of managing Nephrotic syndrome
• Target BP < 125/75
• Target HBAc1 < 6.5%
• Low dose aspirin 75-150mg daily
e) Amyloidosis
AL-primary
AA- secondary
15.5.2. Nephritic syndrome
Description and clinical presentation
• Mild proteinuria
• Hematuria
• High blood pressure
• Acute reduction in GRF
• Some oedema
Causes
Reduced complement
• Post streptococcal Glomerulonephritis
• Shunt Nephritis
378
•
•
•
•
Endocarditis
SLE
HCV
Athero-emboli GN
Normal compliment
• IgA
• HSP
• Anti-GBM
• ANCA positive GN
Clinical features
History of sore throat especially children, features of lupus, purpura(HSP, HCV),
peripheral neuropathy (HSP, HCV), pulmonary haemorrhage (ANCA), chronic
sinusitis (ANCA), associated asthma (ANCA)
Diagnosis
• ANA, ANCA, ds-DNA, ASOT, DNAse, HBsAg, AntiHCV, anti-GBM, RPR,
C3, C4
• Renal biopsy except for post-streptococcal
Therapy
a) Post streptococcal
• Supportive
• BP control
• Antibiotic
• Fluid management
• Dialysis when indicated
• Prognosis good
b)ANCA positive/Anti-GBM
• See under Rapid Progressive Glomerulonephritis
c) Systemic Lupus Erythematosus
• See Lupus Nephritis
d)Others (HBsAg, HCV, IgA, HSP, Shunt nephritis)
• Treat cause
379
15.5.3. Asymptomatic hematuria/proteinuria
Description/Features
• Isolated proteinuria/hematuria with no other features like hypertension,
Edema, renal dysfunction, etc.
• Common Causes in our setting
• Diabetes Mellitus
• SLE
• HIVAN
• FSGS
• UTI
• IgA/HSP
Therapy
Reassure patient and follow up according to underlying disease
15.5.4. Rapid Progressive Glomerulonephritis
Description
• Sub-acute reduction in renal function as opposed to acute nephritis that is
rapid.
• Takes a few weeks to few months for renal function to deteriorate
Clinical features
Similar to acute nephritis except this is more insidious, Hemoptysis, asthma,
sinusitis, epistaxis, abdominal pain, peripheral neuropathy, petechiae, purpura.
Causes
• Type 1
– Anti-Glomerular basement disease (Anti-GBM)
• Type 2
– Immune complex disease
– SLE
– Post streptococcal
– IgA/HSP
• Type 3: ANCA positive
• Polyangiitis with granulomatosis (Wegners)
• Eosinophilic granulomatosis with polyangiitis
(Churg Strauss)
• Microscopic polyangiitis
380
Management
• Serum p-ANCA and C-ANCA
• Renal biopsy is mandatory for light, Immunoflourence, electron microscopy.
1. Anti-GBM RPGN
a. Prednisolone 60 mg/day and reducing
b. Cyclophosphamide 2mg/kg/day and adjusted for white cell count
c.Plasma exchange (50ml/kg to a maximum of 4L daily for 14 days or until antiGBM antibodies undetectable)
d.Treat for 6 months
2. Immune complex RPGN
a. except for Streptococcal, treat as in 3 except plasma exchange may not be
indicated
3. ANCA positive RPGN
a. Methylprednisolone 7mg/kg for 3days and then prednisolone 1mg/kg/day for
4 weeks then taper with either
b. Cyclophosphamide 0.5g/m2 IV monthly for 6 months OR
c. Cyclophosphamide 2mg/kg PO for 6-12 months
d. Plasma exchange for patients with lung haemorrhage and renal dysfunction
e. Co-trimoxazole prophylaxis.
15.5. HYPERTENSION
(See detail on hypertension under section 7.1)
15.5.1. Malignant hypertension
Description
a. BP >180/120
b. Fundal changes/encephalopathy
c. Proteinuria or increased urea/creatinine
d. Thrombotic microangiopathy
Common causes
a. Chronic kidney disease (small kidney on U/S)
b. Acute Nephritis
c. Renal vascular disease (one kidney 1.5cm than the other kidney on U/S)
d. Scleroderma renal crisis
e. Cocaine
f. Other endocrine diseases: - Conn’s, Cushing’s syndrome, etc.
381
Clinical features
a. As above but look for signs of possible aetiology
b. Suspect in elderly Diabetics (atherosclerotic) and young women
(fibromyoplasia)
Management
a. FBC- thrombocytopenia
b. Peripheral smear – RBC fragments
c. Urinalysis
d. U+Es
e. Specific tests to rule out aetiology like kidney sonar, MRI angiogram to rule
out renovascular disease
Therapy
a. Check under cardiovascular disorders
b. ACEI should be given if scleroderma
c. Renal vascular disease needs referral to a specialist if suspected and BP
unresponsive
Increase of serum creatinine <30µmol/l from baseline should not prompt
withdraw of ACEI but monitor closely
d. If dialysis needed peritoneal dialysis preferred to allow possible recovery.
Recovery may take up to several months.
15.5.2. Hypertension or kidney disease in pregnancy
(See HYPERTENSION IN PREGNANCY FOR OTHER DETAILS)
Effects of Pregnancy on kidney
1)Hemodynamic changes lead to hyperfiltration
2)Presence of HTN, Uremia
3)Facts that may predict deterioration
4)Proteinuria
5)Intercurrent pregnancy-related illnesses e.g. Pre-eclampsia
6)Possibility of permanent loss of function Kidney on pregnancy
Effects of Kidney disease on pregnancy
1)Risk of pre-eclampsia
2)Prematurity
3)IUGR
LUPUS Versus Pre-Eclampsia/Eclampsia
382
Other conditions that may present like pre-eclampsia or eclampsia or HELLP
need to be considered.
LUPUS
Lupus flare
Pre-Eclampsia
PROTEINURIA
HTN
RBC CASTS
AZOTEMIA
C3/C4
ABNORMAL LETs
LOW PLTS
+
+
+
+
+
+
+
+
+/-
LOW WBC
+
-
+/+
Thrombotic microangiopathy disorders
– Thrombotic thrombocytopenic purpura
– Hemolytic Uraemic syndrome
Acute Fatty Liver of Pregnancy
Other conditions that may mimic HELLP in pregnancy
HELLP/Ecl
ampsia
AELP
TIP
HUS
Hypertensiom
80%
25-50%
Occasional
Present
Renal
Dysfunction
Mild
to
moderate
Moderate
Mild
to
moderate
Severe
Fever/Neurolo
gical signs/
++
0
++
0
Onset
3rd trimester
3rd
trimester
Anytime
Postpartum
Platelet count
Low
Low
Low
Low
LFTs
High
Very high
Usually
normal
Usually
normal
383
PTT
Normal
high
Antithrombin
III
Low
to
High
Normal
Normal
Low
Normal
Normal
384
LUPUS and PREGNANCY
Poor Outcomes
•
Active disease at conception
•
Disease first appearing in pregnancy
•
HTN, Azotemia in 1st trimester
•
High titres of lupus anticoagulant,
•
Antiphospholipid antibodies
Antiphospholipid antibody in pregnancy
•
Increase fetal loss
•
Venous and arterial thrombosis
•
Renal vasculitis
•
Thrombotic microangiopathy
•
Pre-eclampsia
•
Treatment- ASA, Heparin
15.6.
RENAL AND PANCREATIC TRANSPLANT
15.6.1. Criteria for Renal or/and Pancreatic Transplant
ESKD patients who meet the following criteria will be suitable for
recommendation for Renal or/and Pancreatic Transplant:
•
•
No malignancy or free of malignancy for at least 5 years
No serious cardiovascular disease or ischemic heart disease
(minimum Ejection Fraction of 40%)
•
No Major pulmonary disease
– No major restriction or obstruction
•
No major urological disease
•
No major psychiatric illness
•
BMI< 35 kg/m2
•
Low preformed antibodies (PRAs). High PRAs are associated with
the following – Multiple pregnancies
– Multiple blood transfusions
– Prior failed transplant
•
GI disorders should have been addressed
•
PUD
•
Pancreatitis
•
Diverticulitis
•
Infections
385
•
HIV patients can be transplanted as long as they meet the
following:
– CD4 >200copies/ml
– On HAART for at least 6 months
– VL undetectable
– Adherence with cART
•
All other active infections should be treated first
– Special considerations should be taken for HBV and HCV
•
Should not a smoker or chronic alcoholic
The basic work-work up for a recipient should include the following:
•
•
•
•
•
•
•
•
•
•
a. Serum/blood
HIV test
HBsAg
Anti-HCV
Anti-CMV
Anti-EBV
Anti-HTLV-1
RPR
Blood group
PRAs
X match for CDC and flow cytometry
•
•
•
•
•
•
•
b. Imaging/Invasive
CXR
Doppler US of femoral/iliac veins
ECG
VCU
Gastroscopy
Doppler of carotids for Diabetics
Other tests will be dependent on the condition of patients
c. Other aspects that patient need to meet which are dependent on dialysis
adequacy
•
CaPO4 product should be acceptable
•
PTH within recommended levels
•
Hb 11-12g/dl
•
Potassium normal
386
A checklist should be done the day before transplant to make sure the
candidate is ready if possible do the tests.
Repeat HIV test as well unless already HIV positive Patients should be fully
examined the day before transplant and ensure no comorbidity
d. Stop-or-go Strategy for Evaluation of a Potential Living Donor
•
Blood group determination: Stop if incompatible with recipient blood
group….
•
Plasma Urea, creatinine; proteinuria; urinary sediment:
•
•
•
•
Stop if abnormal
Viral tests: HBV, HCV, HIV Stop if positive
Renal ultrasound: stop if solitary kidney
HLA A, B, DR, DP and DQ typing
CDC Crossmatch; FC crossmatch: Stop if positive (T-cell positive X match
with IgG)
•
•
•
•
•
•
•
•
•
•
e. Full medical evaluation of the potential donor
BMI, blood pressure, cardiac evaluation (at least EKG and ultrasound)
Aorto-iliac CT scan, and renal angiography; urography
Measurement of GFR: Cr51-EDTA, iohexol, or other methods
Blood glucose, HbA1c, cholesterol, microalbuminuria
Liver enzymes, alkaline phosphatases, gGT
Gynecologic evaluation: mammography, uterine cervix smear
Prostate evaluation, clinical and PSA
Evaluation of skin, lung, thyroid, infectious diseases, etc.
Psychologic/ psychiatric evaluation
Validation by urologist and anesthesiologist
•
•
•
•
•
•
•
•
•
•
f. The best kidney donor
Iso blood group and HLA identical
Less than 50 years
Normal BP (< 140/90 mmHg)
BMI < 25 Kg/m2
GFR > 80 ml/min/ 1.73m2
Proteinuria < 300 mg/day; microalbuminuria <30mg/d
No hematuria
No diabetes nor dyslipidemia
No cardiac disease or history of cancer
No infectious (viral) disease
387
15.6.2. Immunosuppression in Live-donor Kidney
patients
•
•
•
•
Transplant
Immunosuppression can be started PRIOR to transplantation, e.g. one
week before; this aims at achieving efficient immunosuppression.
This might result in avoiding induction therapy with ant lymphocyte
preparations or monoclonal anti-IL2 receptor antibody
The HLA matching (D/R) can sometimes be very good, thereby
allowing “lighter” immunosuppression, e.g. avoiding the use of
calcineurin inhibitors
There is no cold ischemia time: thus the risk of delayed graft function
is almost nil, decreasing the risk of acute rejection
15.6.4. Immunosuppression protocols
• Calcineurin inhibitors (Cyclosporine OR Tacrolimus) plus
antiproliferative agent (azathioprine-AZA- OR mycophenolate mofetil –
MMF) with OR without steroids
• With or without induction therapy: anti-lymphocyte agents –ATG- OR
anti-IL2 receptor monoclonal antibodies, e.g. basiliximab, daclizumab
• Calcineurin inhibitors can be avoided (from the beginning or after a few
months) provided there is the use of mTOR-inhibitors such as sirolimus
or everolimus
Induction
• Basiliximab 20 mg pre-operative and day 4
• Methylprednisolone 500mg-1000mg day 0 (in operating theatre)
• MMF or Azathioprine 1.5g or 1-3mg/kg/day respectively
• 4. Cyclosporine 8-12mg/kg stat or Tacrolimus 0.150.30mg/kg/day bd.
Maintenance
• MMF 1.5g BD PO or Azathioprine 1-3mg/kg/day
• Cyclosporine or Tacrolimus (dose adjusted according to C-2 levels or
Tacrolimus levels)
• Prednisolone 60mg first day and taper down fast as long as creatinine
remains stable. By end of the month, the dose should be 20mg or less.
Prophylaxis
• INH 300mg od for 6 months
• Valacyclovir 450mg bd PO (depending on CMV status of “donor and
recipient”) for 3 months
388
•
• Nystatin suspension 10mls od PO for 3months
• Amphotericin B oral suspension for 3 months
Co-trimoxazole 960mg od PO for 6 months
Tacrolimus or Cyclosporine levels to be done daily till discharge then twice
weekly then weekly, fortnightly and so on.
Kidney ultrasound and renogram will be routine within 5 days of transplant
Acute rejection will be defined based on an increase in serum creatinine or
amylase (urine as well) and renal biopsy.
Rejection will be managed under the direct supervision of a Nephrologist but
will require induction agents like ATG or Methylprednisolone or/and
modification of maintenance regimen.
15.6.5. Fertility and Pregnancy post-transplant
•
•
•
•
–
–
–
Fertility restored
Pregnancy outcomes improve if renal function is normal and hypertension
absent
Pregnancy accelerates graft loss
Advisable to wait for 2 years
So that renal function stabilises
Lowest doses of Immunosuppressive
Cyclosporine, prednisolone, Azathioprine safe, MMF no experience.
389
16.
MEDICINE
SAFETY
MONITORING
(PHARMACOVIGILANCE)
Monitoring the safety of medicines is a critical component of Zambia’s
national patient monitoring system as knowledge of adverse drug reactions
and drug interactions helps to generate much-needed safety data to help
improve care and treatment outcomes for patients and consumers of medicinal
products.
All
healthcare
workers,
recipients
of
care/consumers,
manufacturers/distributors and the general public are encouraged to report
safety issues such as adverse drug reactions, medication errors and quality
problems. Everyone is encouraged to report as soon as possible even when
not sure or does not have all the information. Reporting can be made using
various tools which the Ministry of Health has put in place through the
Zambia Medicines Regulatory Authority (ZAMRA). These reporting tools
are:
1.
2.
3.
Paper ADR report form which can be accessed from your pharmacy
department
Mobile phone application Med Safety for android and IOS platforms found
on Play Store and iStore respectively
Electronic reporting form on the ZAMRA website; http://www.zamra.co.zm
Note: Paper ADR reporting forms should be submitted/sent/mailed as soon
as possible to:
The National Pharmacovigilance Unit (NPVU)
Zambia Medicines Regulatory Authority
P.O Box 31890, Lusaka, Zambia
Email: pharmacy@zamra.co.zm
Tel: +260211220429
In the event one is unable to submit directly to NPVU at ZAMRA, forms can
be submitted through the following reporting centres:
1)
2)
3)
4)
5)
6)
ZAMRA regional offices
Regional Pharmacovigilance centers
District Health Office
Provincial Health Office
Responsible officer/In-charge of the dispensary or community pharmacy
Posted at the nearest post office (Zambia Postal Services)
390
391
ZAMBIA ESSENTIAL MEDICINE LIST (ZEML)
392
ZAMBIA ESSENTIAL MEDICINES LIST
Medicine
1
Medicines used in anaesthesia
1.1
General anaesthesia
1.1.1
1.1.1.1
1.1.1.2
1.1.1.3
1.1.1.4
Intravenous and intramuscular anaesthetics
Propofol
Ketamine
Etomidate
Thiopental sodium
1.1.2
Volatile inhalation anaesthetics
1.1.2.1
1.1.2.2
1.1.2.3
Sevoflurane
Isoflurane
Halothane
1.1.3
Local anaesthetics
1.1.3.1
1.1.3.2
1.1.3.3
1.1.3.4
1.1.3.5
Lignocaine
Lignocaine with Adrenaline dental
Bupivacaine without preservatives
Bupivacaine
Bupivacaine with glucose
1.1.4
Anticholinesterases
1.1.4.1
Neostigmine
Presentation
Level
VEN
Emulsion for injection 10mg/ml
Solution for injection 10mg/ml
Powder for injection 1g and 500mg vials
Powder for injection 500mg vials
II - IV
II - IV
II - IV
II - IV
V
V
V
V
Inhalation liquid 250ml
Inhalation liquid 250ml
Inhalation liquid 250ml
II - IV
II - IV
II - IV
V
V
V
Solution for injection 2% w/v, 20mls
Solution for injection
Solution for injection 50mg/ml, (2ml)
Solution for injection 0.5% w/v
Solution for injection 0.5% + 8% w/v
II - IV
I - IV
II - IV
II - IV
I - IV
E
E
E
E
E
Solution for injection 2.5mg/ml, (1ml)
II - IV
V
393
Medicine
Presentation
Level
VEN
Aluminium hydroxide + Magnesium trisilicate
Gel, Chewable tablets
I - IV
E
Aluminium hydroxide
Gel 4%; Tablets 500mg, Oral suspension 4%
I - IV
E
2.1.3
Magnesium trisilicate
Chewable tablets 250mg
I - IV
E
2.1.4
Sodium citrate
Chewable tablets
I - IV
E
2.2
Antispasmodics
2.2.1
Hyoscine butyl bromide
Solution for injection 20mg/ml (1ml), Tablets 10mg
II - IV
E
2.3
Anti-ulcer medicines
2.3.1
Cimetidine
E
2.3.2
Ranitidine
Tablets 200mg, 400mg, 800mg; Syrup/suspension 200mg/5ml, Solution for II - IV
injection 100mg/ml
Tablets 150mg, 300mg, Solution for injection 25mg/ml
II - IV
2.3.3
Famotidine
Tablets 20mg, 40mg
II - IV
E
2.3.4
Omeprazole
Tablets 10mg, 20mg
II - IV
E
2.3.5
Esomeprazole
Tablet/capsule20mg/40mg, Solution for injection 20mg
I - IV
E
2.4
Antidiarrhoeals
2.4.1
Codeine phosphate
Tablets 15mg, 30mg, 60mg
II - IV
E
2.4.2
Loperamide
Tablets/Capsules 2mg, Syrup 1mg/ml
II - IV
E
2
Medicines acting on Gastrointestinal System
2.1
Antacids
2.1.1
2.1.2
394
E
Medicine
Presentation
Level
VEN
Lactulose
Suspension
III
E
Glycerol
Suppository 1g, 4g
I - IV
E
2.5.3
Senna
Tablets 7.5mg, Suppositories
I - III
E
2.5.4
Bisacodyl
Tablets 5mg
I - IV
E
2.6
Medicines used for treating haemorrhoids
2.6.1
Bismuth subgallate + Zinc oxide + Lidocaine hydrochloride
Suppository, Cream
II - IV
E
3
Medicines acting on the Central Nervous System
3.1
Anxiolytics and Antipsychotics
3.1.1
Clonazepam
Tablet 0.5mg
III - IV
E
3.1.2
Lorazepam
Tablets 2mg
III - IV
E
3.1.3
Midazolam
Solution for injection 5mg, 15mg
III - IV
E
3.1.4
Diazepam
Tablets 2mg, Solution for injection 5mg/ml (2ml)
I - III
V
3.2
3.2.1
Selective serotonin reuptake inhibitors
Fluoxetine
Tablets 20mg, 50mg
II - III
E
3.2.2
Sertraline
Tablet 60mg
IV
E
3.2.3
Duloxetine
Tablet 5mg
IV
E
3.2.4
Citalopram
Tablet 10mg, 20mg
IV
E
2.5
Laxatives
2.5.1
2.5.2
395
Medicine
Presentation
Level
VEN
Amitriptyline
Tablets 25mg
III
E
Imipramine
Tablets 25mg
III
E
Clomipramine
Tablets 25mg
III
E
3.3
Tricyclic Antidepressants
3.2.1
3.2.2
3.2.3
3.3
Mood stabilizers
3.3.1
Lithium carbonate
Tablets 300mg
IV
E
3.3.2
Sodium valproate
Tablets 200mg
II - IV
E
3.3.3
Divalproex sodium
Tablet 500mg
IV
E
3.4
Antiepileptic medicines
3.4.1
Carbamazepine
Tablets 200mg, injection 5mg/ml
II - IV
V
3.4.2
Lamotrigine
Tablets 25mg, 50mg
I - IV
V
3.4.3
Ethosuximide
Capsules 250mg
III - IV
V
3.4.4
Phenobarbitone
Tablets 30mg, Solution for injection 200mg/ml
II - IV
V
3.4.5
Phenytoin
Tablets 100mg, Solution for injection 250mg
II - IV
V
3.4.6
Sodium valproate
Tablets 200mg, Syrup 200mg/5ml
II - IV
V
3.4.9
Gabapentin
Tablets 600mg, Oral solution 250mg/5ml
IV
E
3.4.10
Levetiracetam
Tablets 200mg
IV
E
396
Medicine
Presentation
Level
VEN
Bezhexol
Tablets 5mg
II - IV
V
Bromocriptine
Tablets 2.5mg
III - IV
E
3.5.3
Procyclidine
Tablets 5mg, injection 5mg/ml,(2ml)
I - IV
E
3.6
Medicines used for Nausea and Vomiting
3.6.1
Cyclizine
Tablets 50mg, Solution for injection 50mg/ml
IV
E
3.6.2
Domperidone
Tablets 10mg
II - IV
E
3.6.3
Metoclopramide
Tablets 10mg, Solution for injection 5mg/ml (2ml)
II - IV
E
3.6.4
Prochlorperazine
Tablets 5mg
III - IV
E
3.6.5
Promethazine
Tablet 25mg, Solution for injection 25mg/ml (2ml)
I - IV
V
3.6.6
Ondansetron
Tablets 4mg, Oral suspension 2mg, Solution for injection 8mg/2ml
II - IV
E
3.7
Analgesics
3.7.1
Non-opioids analgesics
3.7.1.1
Paracetamol (Acetaminophen)
Tablets 100mg, 500mg, Suppository 125mg, 250mg, Syrup 120mg/5ml
I - IV
V
3.8
Non-Steroidal anti-Inflammatory Medicines
3.8.1
Aspirin
Tablets 75mg, 300mg
II - IV
E
3.8.2
Ibuprofen
Tablets 200mg, 400mg
II - IV
E
3.5
Medicines used in Parkinsonism and related disorders
3.5.1
3.5.2
397
Medicine
Presentation
Level
VEN
3.8.3
Diclofenac
Tablets 50mg, 100mg, Solution for injection 75mg
II - IV
E
3.8.4
Mefenamic acid
Tablets 250mg, 500mg, Suppository 125mg
II - IV
E
3.9
Opioid analgesics
3.9.1
Morphine
Powder, Oral syrup 10mg/5ml, Solution for injection 10mg/ml ampoule II - IV
V
3.9.2
Pethidine
Tablets 50mg, Solution for injection 50mg/ml
II - IV
V
3.9.3
Tramadol
Tablets 50mg, Solution for injection 50mg/ml
II - IV
E
3.9.4
Fentanyl
Solution for injection 50mcg/ml
II - IV
E
Tablets 1mg
II - IV
E
3.10
Anti-migraine medicines
3.10.1
Ergotamine tartrate
4
Medicines used in the treatment of infections
4.1
Antibacterial medicines
4.1.1
Penicillins
4.1.1.1
Benzathine penicillin
Powder for injection 2.4 MU vial
I - IV
E
4.1.1.2
Benzylpenicillin
Powder for injection 5 MU vial
I - IV
V
4.1.1.3
Phenoxymethylpenicillin
Tablets 250mg, Oral suspension 125mg/5ml
I - IV
E
398
Medicine
Presentation
Level
VEN
4.1.2
Broad-spectrum penicillins
4.1.2.1
Amoxycillin
Tablets/Capsules 250mg, Syrup 125mg/5ml
I - IV
V
4.1.2.2
Ampicillin
Powder for injection 500mg vial
III - IV
V
4.1.3
Penicillinase-resistant penicillins
4.1.3.1
Amoxicillin + Clavulanic acid (Co-amoxiclav)
Tablets 375mg (250mg + 125mg), 625mg (500mg + 125mg)
III - IV
E
4.1.3.2
Cloxacillin
Capsules 250mg, Powder for injection 500mg
II - IV
V
4.1.3.3
Flucloxacillin
Capsules 250mg, Powder for injection 250mg
III - IV
E
4.1.4
Aminoglycosides
4.1.4.1
Gentamicin
Solution for injection 40mg/ml, (2ml)
I - IV
V
4.1.5
Sulphonamides
4.1.5.1
Sulfamethoxazole + Trimethoprim (Co-trimoxazole)
Tablets 120mg, 480mg, Oral suspension 240mg/5ml, Solution for
injection 480mg
I - IV
V
399
Medicine
Presentation
Level
VEN
Ciprofloxacin
Tablets 250mg, 500mg
Solution for injection 2mg/ml 100ml,100ml bottle
III - IV
IV
E
4.1.6.2
Nalidixic acid
Tablets 500mg, Oral suspension 30mg/5ml
I - IV
V
4.1.6.3
Ofloxacin
Tablets 400mg, Solution of injection 2mg/ml
I-V
E
4.1.7
Nitro-furan medicines
4.1.7.1
Nitrofurantoin
Tablets 100mg
I - IV
E
4.1.6
Quinolones
4.1.6.1
4.1.8
Macrolides
4.1.8.1
Erythromycin
Tablets 250mg, Powder for injection 500mg vial, Oral suspension
125mg/5ml
I - IV
V
4.1.8.2
Azithromycin
Capsules/Tablets 250mg, Oral suspension 200mg/5ml
II - IV
V
4.1.8.3
Clarithromycin
Tablet 250mg, 500mg
II - IV
V
4.1.9
Lincosamides
4.1.8.3
Clindamycin
Capsules 75mg, Oral suspension 75mg/5ml, Solution for injection
150mg/ml
III - IV
E
4.1.10
Cephalosporins and Cephamycins
4.1.9.1
Cefotaxime
Powder for injection 1g, 250mg vial
III - IV
E
4.1.9.2
Cefoxitine
Powder for injection 1g, 2g vial
II - IV
E
400
Medicine
Presentation
Level
VEN
4.1.9.3
Ceftriaxone
Powder for injection 250mg,1g vial
II - IV
E
4.1.9.4
Cephalexin
Tablets/ Capsules 250mg, Oral suspension 125mg/5ml
III - IV
E
4.1.9.5
Cefuroxime
Tablets 250mg,500mg, Oral suspension 125m/5ml
III - IV
E
4.1.9.6
Cefepime
Powder for injection 1g, 2g vial
III - IV
E
4.1.10
Tetracyclines
4.1.10.1
Doxycycline
Tablets/Capsule 100mg
I - IV
E
4.1.10.2
Tetracycline
Capsule 250mg, Eye ointment 3%
I - IV
E
4.1.11
Nitroimidazoles
4.1.11.1
Metronidazole
Tablets 200mg, Solution for infusion 5mg/ml 100mls, Oral suspension I - IV
100mg/5ml, 100ml
Tablets 500mg
I - IV
V
Capsules 250mg, Oral suspension 125mg/5ml, Powder for injection 1g
vial
V
4.1.11.2
Tinidazole
4.1.12
Other antibacterials
4.1.12.1
Chloramphenicol
401
III - IV
E
Medicine
Anti-tuberculosis medicines
Presentation
Level
VEN
4.2
4.2.1
Rifampicin + Isoniazid
Tablets 150mg + 75mg
HC, I - IV
V
4.2.2
Rifampicin + Isoniazid
Tablets 75mg + 50mg
I - IV
V
4.2.3
Rifampicin + Isoniazid + Ethambutol
Tablets 150mg + 75mg + 275mg
I - IV
V
4.2.4
Rifampicin + Isoniazid + Pyrazinamide
Tablets 75mg + 50mg + 150mg
I - IV
V
4.2.5
Rifampicin + Isoniazid + Ethambutol + Pyrazinamide
Tablets 150mg + 75mg + 275mg+ 400mg
I - IV
V
4.2.6
Ethambutol
Tablets 400mg
I - IV
V
4.2.7
Pyrazinamide
Tablets 400mg
I - IV
V
4.2.8
Isoniazid
Tablets 100mg,150mg
I - IV
V
4.2.9
Streptomycin
Solution for injection 1g, 5g vial
I - IV
V
4.2.10
Capreomycin
Powder for injection 1g
I - IV
V
4.2.11
Levofloxacin
Tablets 250mg
I - IV
V
4.2.12
Ethionamide
Tablets 250mg
II - IV
V
4.2.13
Cycloserine
Tablets 250mg
II - IV
V
4.2.14
Bedaquiline
Tablet 100mg
II - IV
V
4.2.15
Delamanide
Tablet 50mg
II - IV
V
4.2.16
Linezolid
Tablet 600mg
II - IV
V
4.2.17
Clofazimine
Tablet 100mg
II - IV
V
4.2.18
Moxifloxacin
Tablet 400mg
II - IV
V
402
Medicine
Presentation
Level
VEN
Clofazimine
Capsules 50mg,100mg
HC I - IV
V
Dapsone
Tablets 10mg,25mg,50mg
HC I - IV
V
Rifampicin
Capsules 150mg, 300mg, Oral syrup 100mg/5ml
HC I - IV
V
4.3
Anti-leprosy medicines
4.3.1
4.3.2
4.3.3
4.4
Antifungal medicines (also see section 12.3 and 13.3)
4.4.1
Amphotericin B
Solution for injection 50mg
III - IV
E
4.4.2
Clotrimazole
Topical cream 1%, Vaginal tablet 500mg, Mouth paint
HC, I - IV
E
4.4.3
Fluconazole
Capsule 50mg, 150mg, 200mg, Solution for injection 2mg/ml
I - IV
V
4.4.4
Flucytosine
Tablet 250mg, Solution for injection 10mg/ml
III - IV
E
4.4.5
Griseofulvin
Tablets 125mg, 250mg, 500mg, Oral suspension 125mg/5ml
HC, I - IV
E
4.4.6
Miconazole
Topical cream 2%
I - IV
E
4.4.5
Terbinafine
Tablet 250mg, Topical cream/ointment 1%
II - IV
E
4.4.6
Itraconazole
Tablets 100mg
III - IV
E
4.4.6
Nystatin
Vaginal tablets 100,000 IU, Oral suspension 100,000 IU, HC, I - IV
Tablets/Capsules 100,000 IU
V
4.5
Anti-protozoal medicines
4.5.1
Antimalarials
4.5.1.1
Artemether + Lumefantrine
Tablets 20mg/120mg
I - IV
V
4.5.1.2
Pyrimethamine + Sulphadoxine
Tablets 25mg/500mg
I - IV
V
403
Medicine
Presentation
Level
VEN
4.5.1.3
Quinine
Tablets 300mg, Solution for injection 300mg/1ml (2ml)
I - IV
V
4.5.1.4
Artesunate
Powder for injection 60mg,120mg, Suppository 100mg, 200mg HC, I - IV
Tablet 50mg
V
III - IV
V
4.5.2
Amoebocides (See section 4.1.11)
4.6
Trypanomicides
4.6.1
Melarsoprol
Solution for injection 3.6%
4.6.2
Suramin sodium
Powder for injection 1g vial
III - IV
V
4.6.1
Pentamidine isethionate
Powder for nebulizer solution 300mg
II - IV
V
4.8
Antivirals
4.8.1
Acyclovir
Tablets 200mg, 400mg, Topical cream 5%, Solution for injection II - IV
50mg/ml, Powder for injection 500mg, 1g vial, Ophthalmic ointment
3%
E
4.9
Antiretroviral Medicines used in HIV infection
4.9.1
Abacavir
Tablets 300mg
II - IV
E
4.9.2
Lamivudine
Tablets 150mg
II - IV
E
4.9.3
Zidovudine + Lamivudine
Tablets 60mg + 30mg
II - IV
E
4.9.4
Abacavir + Lamivudine
Tablets 60mg + 30mg, 120mg + 60mg
II - IV
E
404
Medicine
Presentation
Level
VEN
4.9.5
Lopinavir/Ritonavir
Oral suspension 80mg/20mg, 100mg/25mg
II - IV
E
4.9.6
Raltegravir
Tablets 100mg
II - IV
E
4.9.7
Tenofovir/Lamivudine
Tablets 300mg/300mg
II - IV
E
4.9.8
Zidovudine
Tablets 100mg, 250mg
II - IV
E
4.9.9
Tenofovir/Lamivudine/Efavirenz
Tablets 300mg/300mg/400mg
II - IV
E
4.9.10
Tenofovir/Lamivudine/Dolutegravir
Tablets 300mg /300mg/50mg
II - IV
E
4.9.11
Tenofovir alafenamide/Emitricitabine/Dolutegravir
Tablets 25mg/200/50mg
II - IV
E
4.9.12
Emitricitabine
Tablets 200mg
II - IV
E
4.9.13
Tenofovir/Emitricitabine
Tablets 300/200mg
II - IV
E
4.9.14
Efavirenz
Tablets 200mg, 400mg
II - IV
E
4.9.15
Nevirapine
Tablets 200mg, Oral suspension 10mg/ml
II - IV
E
4.9.16
Etravirine
Tablets 100mg
II - IV
E
4.9.17
Ritonavir
Tablets 100mg
II - IV
E
4.9.18
Lopinavir/Ritonavir
Tablets 80/20mg, 200/50mg
II - IV
E
4.10
Antihelminthics
4.10.1
Mebendazole
Chewable tablets 100mg, 500mg
HC, HP, I - IV
E
4.10.2
Niclosamide
Tablets 500mg
I - IV
E
4.10.3
Pyrantel pamoate
Tablets 125mg, Oral suspension 250mg/5ml
I - IV
E
4.10.4
Thiabendazole
Tablets 500mg
II - IV
E
4.10.5
Albendazole
Tablets 400mg
II - IV
E
405
Medicine
5.2
Presentation
Level
VEN
Medicines acting on the thyroid
5.2.1
Carbimazole
Tablets 5mg
III - IV
E
5.2.2
Iodine aqueous
Oral solution
III - IV
E
5.2.3
Thyroxine
Tablets 50mcg, 100mcg
III - IV
V
5.3
Corticosteroids
5.3.1
Dexamethasone
Tablets 500mcg, Solution for injection 5mg/ml (5ml)
III - IV
V
5.3.2
Hydrocortisone sodium succinate
Powder for injection 100mg vial
I - IV
V
5.3.3
Prednisolone
Tablets 5mg
I - IV
V
5.4
Oestrogens and progestogens
5.4.1
Norethisterone
Tablets 5mg
III - IV
E
5.4.2
Conjugated Oestrogens
Tablets 625mcg
III - IV
E
5.5
Androgens and anti-androgens
5.5.1
Cyproterone
Tablets 50mg
III - IV
E
5.5.2
Stilboestrol
Tablets 1mg
III - IV
E
5.5.3
Testosterone undecanoate
Capsules 40mg, Solution for injection (oily depot) 250mg/ml,(1ml)
III - IV
E
406
Medicine
Presentation
Level
VEN
Bromocriptine
Tablets 2.5mg
III - IV
E
5.6.2
Clomiphene citrate
Tablets 50mg
III - IV
E
5.6.3
Danazol
Capsules 100mg
III - IV
E
5.7
Medicines used in obstetrics and gynaecology
5.7.1
Medicines acting on smooth muscle
5.7.1.1
Anticonvulsants
5.7.1.1.1
Magnesium sulphate
Solution for injection 50%
II - IV
E
5.7.1.2
Prostaglandin Analogues and Oxytocics
5.6
Other endocrine medicines
5.6.1
5.7.1.2.1
Dinoprostone
Tablets 500mcg, Solution for injection 1mg/ml
III - IV
E
5.7.1.2.2
Ergometrine maleate
Tablets 250mcg, 500mcg, Solution for injection 200mcg/ml
II - IV
V
5.7.1.2.3
Ergometrine + Oxytocin
Solution for injection 50mcg/5 IU
II - IV
E
5.7.1.2.4
Oxytocin
Solution for injection 10 IU/ml,1ml
II - IV
V
5.7.1.2.5
Carbetocin (heat stable)
Solution for injection 100mcg/ ml
HC, I - IV
V
5.7.1.2.6
Misoprostol
Tablets 200mcg
I - IV
V
5.7.1.2.7
Mifepristone
Tablets 200mg
II - IV
V
5.7.1.2.8
Mifepristone + Misoprostol
Tablets 200mg/200mcg
II - IV
V
407
Medicine
Presentation
Level
Salbutamol
Solution for injection 500mcg/ml (1ml)
II - IV
V
Nifedipine
Immediate release capsule, 10mg
HC, I - IV
V
Dexamethasone phosphate
Solution for injection 4mg/ ml
HC, I - III
V
5.7.1.5.2
Tranexamic acid
Tablets 500mg, Solution for injection 100mg/ ml
HC, I - III
V
5.8
Contraceptives
5.8.1
Combined oral contraceptives
5.8.1.1
Ethinylestradiol/levonorgestrel
Tablets 30mg/150mcg
I - IV
V
5.8.2
Emergency contraception
5.8.2.1
Levonorgestrel
Tablets 750mcg,1.5mg
I - IV
V
5.8.3
Progesterone-only oral contraceptives
5.8.3.1
Levonorgestrel
Tablets 30mcg
I - IV
V
5.8.4
Progesterone-only injectable contraceptives
5.8.4.1
Medroxyprogesterone acetate
V
Norethisterone enanthate
Suspension for injection 150mg/ml,1ml
Pre-filled subcutaneous injection 104mg/ 0.65ml
Solution/Emulsion for injection 200mg/ml,1ml
I - IV
5.8.4.2
I - IV
V
5.7.1.3
Myometrial relaxants
5.7.1.3.1
5.7.1.3.2
5.7.1.4
Other medicines administered to the pregnant woman
5.7.1.5.1
VEN
5.8.5
Barrier methods
5.8.5.1
Female condoms
Artificial plastic sheath
HC, I - IV
V
5.8.5.2
Male condoms
Latex sheath with/without spermicide
HC, I - IV
V
408
Medicine
Presentation
Level
VEN
5.8.5.3
Copper coil intrauterine device
Copper long coil type (Copper T 380A) Intrauterine device (IUD)
I - IV
V
5.8.5.4
Levonorgestrel-releasing intrauterine system
Intrauterine device LNG-IUS 52mg
I - IV
V
5.8.5.5
Menfegol spermicidal vaginal foaming
Forming tablets
I - IV
E
5.8.6
Implants
5.8.6.1
Levonorgestrel implant
Two rods, 75 mg each
IV
V
5.8.6.2
Etonogestrel implant
Single rod- releasing implant 68 mg
IV
V
6
Medicines used in the treatment of respiratory system disorders and allergy
6.1
Anti-asthmatic medicines and medicines for chronic obstructive pulmonary
disorder
6.1.1
Adrenaline
Solution for injection 1 in 1000, (1ml)
I - IV
V
6.1.3
Salbutamol
Tablets 2mg, Oral syrup 2mg/5ml
I - IV
V
Inhaler 100mcg/dose, Nebuliser liquid 2mg/ml
I - IV
E
6.2
Corticosteroids
6.2.1
Hydrocortisone sodium succinate
Powder for injection 100mg vial
I - IV
V
6.2.2
Prednisolone
Tablets 5mg
II - IV
V
409
Medicine
Presentation
Level
VEN
Beclomethasone
Inhaler 50mcg/dose
II - IV
E
Sodium cromoglicate
Inhaler 5mg/dose
II - IV
E
Ipratropium bromide
Inhaler 20mcg/ metered dose
II - IV
E
Budesonide + Formoterol
Inhaler 100mcg + 6mcg or 200mcg + 6mcg
II - IV
E
6.3
Asthma prophylaxis therapy
6.3.1
6.3.2
6.3.3
6.4
Antihistamines
6.4.1
Chlorpheniramine
Syrup, Tablets 4mg
I - IV
E
6.4.2
Promethazine
Syrup, Tablets 10mg, Solution for injection 5mg/ml
I - IV
E
6.4.3
Loratidine
Oral liquid 1mg/ml, Tablets 10mg
HC, I - IV
E
6.5
Oxygen therapy
6.5.1
Oxygen
Medical gas
I - IV
V
7
Medicines used in the
treatment of cardiovascular
system disorders
7.1
Cardiac glycosides
7.1.1
Digoxin
Tablets 250mcg, Solution for injection 250mcg/ml, (2ml), Elixir 50mcg/ml
II - IV
V
7.2
Diuretics
7.2.1
Thiazides
7.2.1.2
Bendrofluazide
Tablets 5mg
II - IV
E
410
Medicine
Presentation
Level
VEN
7.2.1.3
Hydrochlorthiazide
Tablets 50mg
II - IV
E
7.2.2
Loop diuretics
7.2.2.1
Frusemide
Tablets 40mg, Solution for injection 10mg/ml, (2ml)
II - IV
V
7.2.3
Potassium-sparing diuretics
7.2.3.1
Amiloride + Hydrochlorthiazide
Tablets 5mg/50mg
II - IV
E
7.2.4
Osmotic diuretics
7.2.4.1
Mannitol
Solution for injection 20% (250ml bottle)
II - IV
V
7.3
Antiarrhythmic medicines
7.3.1
Amiodarone
Tablets 100mg, Solution for injection
III - IV
E
7.3.2
Atenolol
Tablets 50mg
II - IV
E
7.3.3
Digoxin
Tablets 250mcg, Solution for injection 250mcg/ml (2ml)
II - IV
V
7.3.4
Lignocaine
Solution for injection 1%, (10ml, 25ml)
II - IV
V
7.3.5
Quinidine
Tablets 200mg, 300mg
IV
V
411
Medicine
Presentation
Level
VEN
Atenolol
Tablets 50mg
III - IV
E
Glyceryl trinitrate
Sub-lingual tablets 500mcg
II - IV
E
7.4.3
Isosorbide mononitrate
Tablets 10mg
II - IV
E
7.4.4
Nifedipine
Tablets or Capsules 10mg
II - IV
E
Tablets 50mg
II - IV
E
7.4
Anti-angina medicines
7.4.1
7.4.2
7.5
Antihypertensive medicines
7.5.1
Thiazide diuretics
7.5.1.1
Hydrochlorthiazide
7.5.1.2
Potassium-sparing diuretics
7.5.1.2.1
Amiloride + Hydrochlorthiazide
Tablets 5mg/50mg
II - IV
E
7.5.1.2.2
Spironolactone
Tablets 25mg
II - IV
E
7.5.2
Beta- adrenoceptor blockers
7.5.2.1
Atenolol
Tablets 50mg
II - IV
E
7.5.2.2
Propranolol
Tablets 10mg, 40mg
II - IV
E
7.5.2.3
Carvedilol
Tablets 3.125mg
IV
E
7.5.2.4
Labetalol
Tablets 100mg, Solution for injection 5mg/ml
III - IV
E
7.5.2.5
Metoprolol
Tablets 50mg, 100mg
III - IV
E
412
Medicine
7.5.3
Vasodilators
7.5.3.1
Hydralazine
7.5.4
Angiotensin-converting enzyme (ACE) inhibitors
Presentation
Level
VEN
Tablets 25mg, Solution for injection 20mg ampoule
II - IV
E
7.5.4.1
Captopril
Tablets 25mg
III - IV
E
7.5.4.2
Lisinopril
Tablets 5mg, 10mg, 25mg
III - IV
E
7.5.4.3
Enalapril
Tablets 5mg, 10mg, 20mg
III - IV
E
7.5.5
7.5.5.1
7.5.5.2
7.5.5.3
Angiotensin II receptor blockers
Losartan
Losartan + Hydrochlorthiazide
Telmisartan + Hydrochlorthiazide
Tablets 25mg, 50mg
Tablets 50mg/12.5mg
Tablets 40mg/12.5mg
IV
HC, I - IV
HC, I - IV
E
E
E
7.5.6
Calcium channel blockers
7.5.6.1
Nifedipine
Tablets or Capsules 10mg, 20mg
III - IV
E
7.5.6.2
Verapamil
Tablets 40mg
III - IV
E
7.5.6.3
Amlodipine
Tablets 5mg, 10mg
III - IV
E
7.5.7
Centrally acting antihypertensives
7.5.7.1
Methyldopa
Tablets 250mg
HC, I - IV
E
413
Medicine
7.6
Medicines used in shock - sympathomimetics
7.6.1
Adrenaline
7.7
Alpha-adrenoceptor blocking agents
7.7.1
Prazosin
7.8
Lipid-regulating medicines
7.8.1
Statins
Presentation
Level
VEN
Solution for injection 1 in 1000 (1mg/ml)
I - IV
V
Tablets 500mcg, 1mg
III - IV
E
7.8.1.1
Simvastatin
Tablets 20mg, 40mg
IV
E
7.8.1.2
Atorvastatin
Tablets 20mg, 40mg
II - IV
E
7.9.1
Inotropic medicines
Solution for injection 40mg/ml
IV
E
7.9.1.1
Dopamine
8
Medicines used in the treatment of malignant diseases: Anti-neoplastic medicines
8.1
Actinomycin D (Dactinomycin)
Powder for injection 500mcg
III - IV
V
8.2
Asparaginase
Powder for injection 1000 IU
III - IV
V
8.3
Azathioprine
Tablets 50mg, injection 50mg vial
IV
V
8.4
Bleomycin
Powder for injection 15 000 unit ampoule
IV
V
8.5
Busulphan
Tablets 500mcg
IV
V
8.6
Calcium folinate
Tablets 15mg
IV
V
8.7
Carboplatin
Solution for injection 10mg/ml
IV
V
8.8
Carmustine
Powder for injection 100mg vial
IV
V
414
Medicine
Presentation
Level
VEN
8.37
Thioguanine
Tablets 40mg
IV
V
8.38
Vinblastine
Solution for injection 1mg/ml
IV
V
8.39
Vincristine
Solution for injection 1mg, 5mg
III - IV
V
9
Medicines acting on the eye
9.1
Ophthalmic diagnosis
9.1.1
Fluorescein sodium
Eye drops, strips
III - IV
E
9.2
Anti-infective preparations
9.2.1
Antibacterial
9.2.1.1
Chloramphenicol
Eye drops 0.5%, Eye ointment 1%
II - IV
E
9.2.1.2
Chloramphenicol + Dexamethasone
Eye drops 15%/ 0.1%
III - IV
E
9.2.1.3
Tetracycline
Eye ointment 1%
I - IV
E
9.2.1.4
Oxy-tetracycline + Hydrocortisone
Eye drops 3%/ 1%
III - IV
E
9.2.1.5
Neomycin + Betamethasone
Eye drops 0.5%/ 0.1%
III - IV
E
9.2.1.6
Gentamicin
Eye drops 0.3%
II - IV
E
9.2.1.8
Ofloxacin
Solution 0.3%
III - IV
E
415
Medicine
Presentation
Level
VEN
8.9
Chlorambucil
Tablets 2mg
IV
V
8.10
Cisplatin
Solution for injection 1mg/ml
IV
V
8.11
Cyclophosphamide
Tablets 50mg, Powder for injection 100mg
IV
V
8.12
Cytarabine (Cytosine arabinoside)
Powder for injection 100mg, 500mg, 1g vial
IV
V
8.13
Cyproteron acetate
Tablets 50mg, 100mg
IV
V
8.14
8.15
Dacarbazine
Daunorubicin
Powder for injection 200mg vial
Powder for injection 20mg vial
IV
IV
V
V
8.16
Doxorubicin
Powder for injection 10mg,50mg
IV
V
8.17
Etoposide
Solution for IV infusion 20mg/ml
IV
V
8.18
Fludarabine
Tablets 10mg, Solution for injection, infusion 40mg/m2
IV
V
8.19
Filgrastim
Solution for injection 300mcg/ml
IV
V
8.20
Fluorouracil
Solution for injection 25mg/ml
IV
V
8.21
Hydroxyurea
Capsules 500mg
IV
V
8.22
Ifosfamide
Powder for injection 1g, 2g vial
IV
V
8.23
Imatinib
Tablets 100mg
IV
V
8.24
Interferon
Solution for injection 300mg
IV
V
8.25
Lomustine
Capsules 40mg
IV
V
8.26
Melphalan
Tablets 2mg, Solution for injection 100mg
IV
V
8.27
Mercaptopurine
Tablets 50mg
IV
V
8.28
Methotrexate
Tablets 2.5mg, Solution for injection 50mg
IV
V
8.29
Mitomycin
Solution for injection 40mg
IV
V
8.30
Mustine
Solution for injection 10mg
IV
V
8.31
Paclitaxel
Solution for IV infusion 6mg/ml
IV
V
8.32
Procarbazine
Capsules 50mg
IV
V
8.33
Stilboestrol (Diethylstilbestrol)
Tablets 1mg
IV
V
8.34
Tamoxifen
Tablets 20mg
IV
V
416
Medicine
Presentation
Level
VEN
Povidine Iodine
Eye drops 0.5%
III - IV
E
9.2.2.2
Natamycin
Eye suspension 5%
IV
E
9.2.3
Antiviral
9.2.3.1
Aciclovir
Eye ointment
III - IV
E
9.3
Anti-inflammatory preparations
9.3.1
Hydrocortisone acetate
Eye drops, eye ointment
II - IV
E
9.3.2
Dexamethasone
Eye drops 0.1%
III - IV
E
9.3.4
Tropicamide
Eye drops 1%
III - IV
E
9.3.5
Sodium cromoglycate
Eye drops 2%
III - IV
E
9.4
Miotics and anti-glaucoma medicines
9.4.1
Pilocarpine
Eye drops 2%, 4%
III - IV
E
9.5
Mydriatic medicines
9.5.1
Atropine sulphate
Eye drops 1%
III - IV
E
9.2.2
Antifungals
(Preparations are not generally available and could be prepared extemporaneously)
9.2.2.1
417
Medicine
9.6
Systemic preparations
9.6.1
Acetazolamide sodium
9.7
Local anaesthetics
9.7.1
Lignocaine hydrochloride
9.8
Prostaglandin Analogue
9.8.1
Latanoprost
9.9
Sympathomimetics
9.9.1
Dipivefrine
9.10
Beta-adrenoceptor blocker
9.10.1
Timolol maleate
9.11
Diuretics
9.11.1
Cyclopenthiazide
9.12
Artificial tears
9.12.1
Hypromellose
Presentation
Level
VEN
Tablets 250mg
III - IV
V
Eye drops 4%
III - IV
E
Eye drops 50mcg/ml
IV
E
Eye drops 0.1%
IV
E
Eye drops 0.25%, 0.5%
III - IV
E
Tablets 0.5mg
IV
E
Eye drops 0.3mg
III - IV
E
418
Medicine
Presentation
Level
VEN
Mannitol
Solution in water 20%
III - IV
E
9.13.2
Urea
Solution 30% in 10% invert sugar
III - IV
E
10
Blood and Blood Products
9.13
Hyperosmotic agents
9.13.1
10.1
Anti-coagulants
10.1.1
Heparin (Unfractionated)
Solution for injection 5000IU/ml,1ml
II - IV
V
10.1.2
Enoxaparin
Solution for injection 100mg/ml, Pre-filled syringes
II - IV
V
10.1.3
Warfarin
Tablets 1mg, 5mg
II - IV
V
10.2
Anti-haemorrhagic medicines
10.2.1
Aminocaproic acid
Effervescent powder 3g, Oral suspension 10mg/5ml
III - IV
E
10.2.2
Tranexamic acid
Solution for injection 100mg/ml, Tablets 650mg
III - IV
E
10.2.2
Fibrinogen
Dry or freeze dried powder for injection
III - IV
V
10.2.3
Human anti-haemophiliac fraction (dried)
Solution for reconstitution 3 units/ml
IV
E
10.2.4
Phytomenadione (Vitamin K)
Solution for injection 10mg/ml,(1ml)
II - IV
V
10.3
Haematinics
10.3.1
Ferrous sulphate
Tablets 50mg, 200mg
HC, I - IV
V
10.3.2
Folic acid
Tablets 5mg, 400mcg
HC, I - IV
V
10.3.3
Hydroxocobalamin (Vitamin B12)
Solution for injection 1mg/ml,1ml
II - IV
E
10.3.4
Iron dextran
Solution for injection 50mg iron in 2ml ampoule
II - IV
E
419
Medicine
Presentation
Level
VEN
11
Nutrition
11.1
Vitamins, minerals and dietary supplements
11.1.1
Ascorbic acid (vitamin C)
Tablets 50mg, 200mg
I - IV
E
11.1.2
Calcium gluconate
Solution for injection 10%, (5ml,10ml)
III - IV
E
11.1.3
Ergocalciferol (Vitamin D)
Tablets 50,000 IU, solution 3000 IU/ml
II - IV
E
11.1.4
Nicotinamide
Tablets 50mg
II - IV
E
11.1.5
Pyridoxine (Vitamin B6)
Tablets 50mg
I - IV
E
11.1.6
Retinol (Vitamin A)
Capsules/ Tablets 200,000IU
I - IV
E
11.1.7
Riboflavin (Vitamin B2)
Tablets 5mg
III - IV
E
11.1.8
Thiamine (Vitamin B1)
Tablets 50mg, Solution for injection 100mg/5ml
III - IV
E
11.2
Electrolyte and water replacement
11.2.1
Orally administered
11.2.1.1
Oral rehydration salts
Powder sachets 27.9g to make 1 litre
I - IV
V
11.2.1.2
Potassium chloride
Tablets slow-release 600mg
II - IV
E
11.2.2
Infusions
11.2.2.1
Dextrose (glucose)
Solution 5%, 20, 50%
I - IV
V
11.2.2.2
Potassium chloride
Solution 11.2%
II - IV
E
11.2.2.3
Sodium bicarbonate
Solution 4.2%
III - IV
V
11.2.2.4
Sodium chloride (normal saline)
Solution 0.9%
I - IV
V
11.2.2.5
Sodium lactate and glucose (Darrow’s)
Solution, full and half strength
I - IV
V
420
Medicine
Presentation
Level
VEN
12.4
Topical anti-bacterial preparations
12.4.1
Mupirocin
Cream, Ointment 2%
I - IV
E
12.4.2
Silver sulfadiazine
Cream 1%
I - IV
E
Topical solution 1:10,000
I - IV
E
12.5
Antiseptic preparations
12.5.1
Potassium permanganate
12.6
Topical anti-parasitic preparations
12.6.1
Benzyl benzoate
Lotion 25%
I - IV
E
12.6.2
Malathion
Lotion 0.5%
I - IV
E
12.6.3
Permethrin
Cream 1%
I - IV
E
12.7
Keratoplastics and keratolytics
12.7.1
Coal tar
Solution 5%
I - IV
E
12.7.2
Dithranol
Ointment 1%
III - IV
E
12.7.3
Podophylline
Paint 15% in compound benzoin tincture
II - IV
E
12.7.4
Salicylic acid
Ointment 5%, 10%, 20%
I - IV
E
12.8
Acne preparations
12.8.1
Salicylic acid
Lotion
I - IV
E
12.8.2
Benzyl peroxide
Lotion
I - IV
E
421
Medicine
Presentation
Level
VEN
11.2.2.6
Sodium lactate compound (Ringers lactate)
Solution
I - IV
V
11.2.2.7
Water for injection
Solution 2ml, 5ml, 10ml
I - IV
V
11.2.3
Plasma substitutes
11.2.3.1
Dextran 40, 70
Solution for injection 10%, 6%
III - IV
V
11.2.3.2
Gelatin (as polygeline)
Solution for injection 3.5
III - IV
E
12
Medicines acting on the skin
12.1
Topical corticosteroids
12.1.1
Betamethasone
Cream/ Ointment 0.1%
III - IV
E
12.1.2
Hydrocortisone
Cream/ Ointment 1%
I - IV
E
Lotion
I - IV
E
Cream 2%
III - IV
E
12.2
Soothing preparations
12.2.2
Calamine
12.3
Topical antifungal preparations
12.3.1
Miconazole nitrate
12.3.2
Ketoconazole
Cream
I - IV
E
12.3.3
Griseofulvin
Tablets 250mg, 500mg
II - IV
E
422
Medicine
Presentation
Level
VEN
12.9
Surgical disinfectants
12.9.1
Sodium hypochlorite
Solution 0.1% available chlorine
I - IV
V
12.9.2
Chloroxylenol
Concentrated solution 4.8%
I - IV
E
12.10
Antiseptics
12.10.1
Cetrimide
Solution 1%
I - IV
E
12.10.3
Chlorhexidine gluconate
Concentrated solution 5%
I - IV
E
12.10.2
Chlorhexidine + Cetrimide
Concentrated solution (1.5%/ 15%)
I - IV
E
12.10.4
Povidone iodine
Solution 10%
I - IV
V
12.11
Topical antivirals
12.11.1
Acyclovir
Cream 5%, Tablets 200mg
II - IV
E
13
Medicines used in the treatment of diseases of the ear, nose and throat
13.1
Medicines acting on the ear
13.1.1
Betamethasone
Ear drops
III - IV
E
13.1.2
Gentamicin + Hydrocortisone
Ear drops
II - IV
E
423
Medicine
Presentation
Sodium bicarbonate
Ear drops
13.1.4
Olive oil (Vegetable oil)
13.1.5
Acetic acid
13.2
Medicines acting on the nose: topical nasal decongestants
13.1.3
Level
VEN
III - IV
E
Ear drops
I - IV
E
Solution 2%
I - IV
E
13.2.1
Saline
Nasal drops
II - IV
E
13.2.2
Xylometazoline
Nasal drops 0.25%, 0.05%
I - IV
E
13.3
Medicines acting on the throat
13.3.1
Chlorhexidine
Mouth wash 0.2%
I - IV
E
13.3.2
Miconazole
Oral gel
I - IV
E
13.3.3
Nystatin
Oral suspension
I - IV
E
14
Medicines used for the treatment of musculoskeletal disorders
14.1
Medicines used for rheumatic diseases
14.1.1
Acetyl salicylic acid
Tablets 300mg
I - IV
V
14.1.2
Ibuprofen
Tablets 200mg
I - IV
E
14.1.3
Hydroxychloroquine
Tablets 200mg
III - IV
E
424
Medicine
Presentation
Level
VEN
15.2.8
Tetanus toxoid (TT)
Injection
I - IV
V
15.2.9
Typhoid
Injection
III - IV
E
15.2.10
Yellow fever
Injection
III - IV
E
15.2.11
Human Papilloma Virus (HPV)
Injection
III - IV
E
15.2.12
Rota Virus
Injection
III - IV
E
15.2.13
Pneumococcal Conjugate Vaccine 13
Injection
III - IV
E
15.2.14
Cholera
Injection
III - IV
E
16
Antidotes and other substances used in poisoning
16.1
General treatment of poisoning
16.1.1
Activated charcoal
Powder
I - IV
V
16.1.2
Ipecacuanha
Syrup 0.14% ipecacuanha alkaloids
I - IV
V
16.2
Specific treatment of poisoning
16.2.1
Atropine
Injection 1mg/ml, (1ml)
III - IV
V
16.2.2
Naloxone
Injection 400mcg/ml
III - IV
V
16.2.3
Pralidoxine mesylate
Injection 200mg/ml, (5ml)
III - IV
V
16.2.4
Glycopyrronium bromide
Injection 500mcg/ml
III - IV
V
16.2.5
N-acetylcysteine
Solution 20%
IV
E
16.2.6
Protamine sulphate
Injection 10mg/ml
IV
E
425
ESSENTIAL LABORATORY SUPPLIES LIST
426
TEST
CD4 estimation
REAGENT
BD FACSCalibur
BD Tritest CD3/CD4/CD45 with TruCount Tubes
BD Calibrate 3 Beads
BD FACS Lysing Solution
True Count Control
BD FACSCount
BD FACS Count CD4/CD8 Reagents
BD FACS Count Controls
BD FACS Rinse Solution
BD FACS Clean Solution
BD FACS Flow Sheath Fluid
BD FACSCount Thermal Paper
Guava
Guava Auto CD4/CD4 % reagent kit
Guava easy CD4 microcentrifuge tube
Guava check kit
Guava cleaning fluid
UNIT PACK
Kit of 50 tests
Kit of 25 tests
100 ml
Kit of 30 test
Kit of 50 tests
Kit of 25 tests
5L
5L
20 L
Roll
100 tests
500 x 1.5 ml
50 tests
100 ml
427
Full Blood count
Sysmex PocH 100i
Eight Check-H
Eight Check-N
Eight Check-L
PocH pack 65
Sysmex Clean
Sysmex Thermal Paper
ABX Micros 60/80
ABX Minotrol 16 Twin Pack Low
ABX Minotrol 16 Twin Pack Normal
ABX Minotrol 16 Twin Pack High
ABX Miniclean
ABX Minilyse
ABX Minidil
ABX Pentra 60C+/80XL
ABX Difftrol Twin Pack Low
ABX Difftrol Twin Pack Normal
ABX Difftrol Twin Pack High
ABX Lysebio
ABX Basolyse
ABX Cleaner
1.5 ml
1.5 ml
1.5 mL
Pack of 2.7L pack D and 50ml pack L
50ml
Roll
2 x 2.5 ML
2 x 2.5 ML
2 x 2.5 ML
1L
1L
20 L
2 x 3ML
2 x 3ML
2 x 3ML
400 ml
1L
1L
428
Full Blood count
Clotting profile
ABX Diluent
ABX Eosinofix
Sysmex XS 800i/XS1800i/XT 2000i
Sysmex control e-Check Low
eCheck Sysmex control e-Check Normal
Sysmex control e-Check High
Sysmex Cell pack
Sysmex Stromatolyser 4DL
Sysmex Stromatolyser 4DS
Sysmex Sulfolyser
Sysmex Cell clean
Sysmex Retsearch Diluent/Dye
Sysmex Stromatolyser FB
20 L
1L
8 x 4.5ML
8 x 4.5ML
8 x 4.5ML
20L
5L
3 x 42 ML
5L
50ML
1L
5L
Coagulation
Activated Partial thromboplastin time (APTT) test kit
Prothrombin Time (PT) test kit
Thrombin Time (TT) test
CaCl 0.025mmol/L
Factor VIII deficient plasma
Factor IX deficient plasma
Fibrin degradation products
each
each
each
10 ml
vial
vial
kit
429
Peripheral smear
Special Stains
Clotting profile
Peripheral smear
HAEMATEK slide stainer
Blood film stain pack
Bone marrow stain pack
Cytochemistry
Glucose 6 phosphate dehydrogenase (G6PD)
Sudan black B stain
Myeloperoxidase
Antinuclear antibody test by indirect method
pack
pack
kit
kit
kit
kit
Coagulation
Activated Partial thromboplastin time (APTT) test kit
Prothrombin Time (PT) test kit
Thrombin Time (TT) test
CaCl 0.025mmol/L
Factor VIII deficient plasma
Factor IX deficient plasma
Fibrin degradation products
HAEMATEK slide stainer
Blood film stain pack
Bone marrow stain pack
each
each
each
10 ml
vial
vial
kit
pack
pack
430
Special Stains
Clinical chemistry
Cytochemistry
Glucose 6 phosphate dehydrogenase (G6PD)
Sudan black B stain
Myeloperoxidase
Antinuclear antibody test by indirect method
kit
kit
kit
kit
Cobas Integra 400
Cobas ALT/ GPT
Cobas AST/ GOT
Cobas Creatinine
Cobas Urea
Cobas Cholesterol
Cobas Glucose
Cobas Triglycerides
Cobas Bilirubin Total
Cobas Bilirubin Direct
Cobas Total Protein
Cobas Albumin
Cobas Cfas
Cobas Precinorm U
Cobas Precipath U
Cobas Deproteinizer
500 test cassette
500 test cassette
700 test cassette
500 test cassette
400 test cassette
800 test cassette
250 test cassette
500 test cassette
500 test cassette
400 test cassette
300 test cassette
36 ml
4 X 5 ml
4 X 5 ml
23 ml
431
Clinical chemistry
Cobas Amylase
Cobas Lipase
Cobas Lactate
Cobas Cuvettes
Cobas Sample cups (white)
Cobas Control cups (brown)
Cobas Waste container
Cobas Cleaner
Cobas c 111
Cobas ALT/ GPT
Cobas AST/ GOT
Cobas Creatinine
Cobas ALP
Cobas Urea
Cobas Cholesterol
Cobas Glucose
Cobas Triglycerides
Cobas Bilirubin Total
Cobas Bilirubin Direct
Cobas Total Protein
Cobas Albumin
300 test cassette
200 test cassette
300 test cassette
Pack of 2000 cuvettes
Pack of 1000 cups
Pack of 1000 cups
Each
1L
4 x 100 test
4 x 100 test
2 x 200 test
4 x 50 test
4 x 100 test
4 x 100 test
4 x 100 test
4 x 50 test
4 x 100 test
4 x 50 test
4 x 100 test
4 x 100 test
432
Clinical chemistry
Cobas Bicabonate
Cobas HbA1C
Cobas LDH
Cobas Uric
Cobas Amylase
Cobas Lipase
Cobas Lactate
Cobas Cuvettes
Cobas Sample cups (white)
Cobas Control cups (brown)
Cobas Waste container
Cobas Cleaner
Humalyzer 2000
Human ALT(GPT) Liquicolor UV
Human AST(GOT) Liquicolor UV
Human Creatinine Liquicolor
Human Glucose Liquicolor
Human Urea Liquicolor
Human Bilirubin Direct
Human Bilirubin Total
Humatrol Normal (N19)
4 x 100 test
400 test
4 X 50 tests
4 x 100 tests
4 x 100 tests
4 x 50 tests
4 x 50 tests
Pack of 2000 cuvettes
Pack of 1000 cups
Pack of 1000 cups
Each
1L
10 X 10 ml
10 X 10 ml
200 ml
1L
2 X 100 ml
100 ml
100 ml
6 X 5 ml
433
Clinical chemistry
Humatrol Pathological (P17)
Humalyzer 2000 Thermal Printing Paper
Humalyzer 2000 Cuvettes
Humalyte
Na
Cl
K
Olympus AU400
Olympus ALT
Olympus AST
Olympus Cholesterol
Olympus Cholesterol HDL
Olympus Bilirubin Direct
Olympus Bilirubin Total
Olympus Electrode Na+
Olympus Electrode K+
Olympus Electrode Cl
Olympus ISE Buffer
Olympus Mid ISE Standard
Olympus Electrode Cleaning Solution
Olympus Control Serum 1
6 X 5 ml
Roll
Pack of 1000
ISE
ISE
ISE
4x12, 4x6 ml
4x6, 4x4 ml
4 X 22.5 ml
4 X 22.5 ml
4 X 25 ml / 4 X 25 ml
2 X 100 ml
Each
Each
Each
1L
2L
2 X 50 ml
20 X 5 ml
434
Clinical chemistry
Olympus Control Serum 2
Olympus Creatinine
Olympus Glucose
Olympus System Calibrator
Olympus Triglyceride
Olympus Urea
Olympus Wash Solution
Olympus Total Protein
Olympus Albumin
Olympus Amylase
Olympus Lipase
Olympus Lactate
Pentra 200/400
Alanine Aminotransferase (ALT/GPT)
AST (Cobas III)
Creatinine
Urea
Cholesterol
Glucose
Total Protein
Bilirubin Total
20 X 5 ml
4 X 60 ml
4x25 ml/ 4x12.5 ml
20 X 5 ml
4x50 ml/ 4x12.5 ml
2x4x25 ml
5L
500 test cassette
500 test cassette
?
?
?
1*70ml
1*90ml
1*90ml
1*90ml
1*90ml
1*90ml
1*90ml
1*90ml
435
Clinical chemistry
Cuvette Segements Rack
Control Pathological
Control Normal
Amylase
Lipase
Lactate
Deproteinizer
Standard 1
Standard 2
Reference
1*90ml
1*90ml
1*90ml
1*90ml
1*90ml
1*90ml
1*30ml
100ml
100ml
100ml
HIV Viral load and
qualitative tests
Cobas Taqman 48 analyser
CAP/CTM HIV - version 2.0
COBAS TaqMan K Tubes
CAP - G Wash Buffer
CAP SPU Flapless
CAP S Tubes (input)
CAP K tips
DNA PCR - Pediatric
DNA, PCR AMPLICOR HIV-/ Monitor Test
PCR Consumables Kits, for 960 Tests
DBS Bundles for 50 tests
Kit of 96 tests
Kit for 960 tests
Bundles for 50 tests
436
Bacteriology
Glucose test
Hepatitis tests
Acetone
Ammonium Oxalate
Bacitracin 0.04units
Basic Fuchsin Powder
Blood Culture Media Adult
Blood Culture Media Pediatric
Blood Agar Base
MacConkey agar with crystal violet
Campylobacter Karmali Agar
Bacitracin 0.04units
Basic Fuchsin Powder
Cary Blair
Simmon Citrate Agar
Crystal Violet Powder
Cystine Lactose Electrolytes Deficient Agar (CLED medium)
Mueller Hinton Agar
N,N,N,N Tetramethyl-P-Phenylene Diamine (Oxidase Reagent)
Orange G 6 Solution
L
g
250 discs
g
Bottle
Bottle
g
Accucheck active Glucometer Strips
Hepatitis B Test Kit
Hepatitis C Test kit
Strips
Strips
strips
437
g
250 discs
g
g
g
g
g
g
g
L
Histopathology
General laboratory
use
Syphilis
Meningitis
investigation
Pregnancy
Stool
Microscopy
culture
and
identification
Ethanol Absolute (99.9%)
Methanol Absolute
Formalin
Hydrochloric Acid
L
L
L
L
Kovacs Reagent
RPR (syphilis reagent kit)
Cryptococcus Antigen Test Kit
ml
Tests
Tests
Pregnancy Test Kit (Latex)
Salmonella Typhi Hd antisera
Salmonella Typhi Vi antisera
Salmonella Typhi O-9 antisera
Salmonella Paratyphi A antisera
Salmonella Paratyphi B antisera
Salmonella Paratyphi C antisera
Salmonella Polyvalent H Phase 1 and 2 Antisera
Salmonella Polyvalent O groups A - S Antisera
Selenite F Broth
Shigella boydii types 1 - 6
Shigella boydii types 12 - 15
Tests
2ml
2ml
2ml
5 ml
5 ml
5 ml
5 ml
5 ml
g
5 ml
438
Stool Microscopy
culture
and
identification
Shigella boydii types 7 - 11
Shigella disenteriae type 1 -10 antisera
Shigella disenteriae type 1 antisera
Shigella flexneri types 1-6, x,y Antisera
Shigella sonnei Phase 1 and 2 antisera
General laboratory
use
Bacteriology (MCS)
Sodium Chloride (Analar grade)
g
Sulphide Indole Motility (SIM) medium
Triple Sugar Iron Agar (TSI)
Urea Agar
Urea (analar grade)
Urine Multistix
g
g
g
g
Pack of 100 Strips
Deoxycholate citrate agar (DCA) agar
Ampicillin 10 µg
Cefotaxime 30µg
Chloramphenicol 30 µg
Ciprofloxacin 5 µg
Cotrimoxazole 25 µg
Erythromycin 15 µg
Gentamicin 10 µg
Nalidixic Acid 30 µg
g
250 discs
250 discs
250 discs
250 discs
250 discs
250 discs
250 discs
250 discs
Urinalysis
Bacteriology (MCS)
5 ml
5 ml
5 ml
439
Bacteriology (MCS)
Histopathology
Malaria
Nitrofurantoin 300 µg
Penicillin 10 units
Oxacillin 1 µg
Norfloxacin 10 µg
Chloroform
Haematoxylin (Harris Alum Haematoxyllin)
DPX Mountant
EA 50
Acetic acid
Giemsa powder
Glycerol
Aesculine-bile agar
Peptone water
Lysine Iron agar
Sabourauds agar
Thiosulphate citrate bile-salt sucrose (TCBS) medium
Tryptone soy broth
0.5 McFarland standard (Latex)
Amyl alcohol
Chlamydia test kit
440
250 discs
250 discs
250 discs
250 discs
L
ml
ml
ml
g
5L
Malaria
General laboratory use
Bacteriology (MCS)
General Laboratory
use
Special stains
Coagulase test (Commercially prepared kit e.g. StaphAurex kit or
equivalent)
diSodium hydrogen phosphate (Na2HPO4) Anhydrous
Eosin powder
Hydrogen peroxide
Iodine
Methylene blue
Nigrosin
p-dimethylamino benzaldehyde powder
Phenol crystals
Potassium hydroxide
Potassium iodide
Potassium permanganate
Sodium biselenite powder
Sodium hydroxide crystals
Sodium dihydrogen phosphate (NaH2PO4.2H2O) hydrated
Streptococcus Lancefield typing kit (e.g. Streptex kit or equivalent)
Sulphuric acid
Toluidine blue O stain
441
Toxoplasmosis
General
Bacteriology (MCS)
Toxoplasma antigen detection test
Xylene
Formic Acid
Cefoxitin 30 µg (Disc)
Ceftazidime30 µg (Disc)
Ceftriaxone 30 µg (Disc)
Colistin 10 µg (Disc)
Polymyxin B 300 Units (Disc)
E-test strips
Cefotaxime (E-test)
Penicillin (E-test)
Diagnostic discs
Colistin 10 µg (Disc)
Furazolidone 100 µg (Disc)
Indole test discs
Nitrocefin discs
Novobiocin 5 µg (Disc)
Optochin disc
Polymyxin B 300 units (Disc)
Pyrrolidonyl arylamidase test (PYR) discs
V factor (Disc)
442
Bacteriology (MCS)
Bacteriology (MCS)
Endocrinology
Cancer
X factor (Disc)
XV factor (Disc)
Antisera
Vibrio cholerae O1 polyvalent antisera
Vibrio cholerae O139 antisera
Vibrio cholerae Inaba antisera
Vibrio cholerae Ogawa antisera
E.coli O 157:H7 antisera
Clavulanic Acid Powder
Streptococcus pyogenes group A Rapid test strips
Streptococcus agalactiae group B Latex agglutination antigen detection kit
Gonorrhoea Rapid test strips
Thyroid Hormones
TSH
T3
T4
Tumour Markers
CEA
PSA
AFP
443
Heart/cardiac
General laboratory use
Cardiac Markers
CK MB
CKNAC
Troponin T
Troponin I
General Consumables
Applicator Sticks, Orange
Cotton Wool
Filter Paper, Medium
Filter Paper, Large
Examination Gloves, Medium
Examination Gloves, Large
Sodium Hypochlorite (Jik)
Lancets
Kimwipes
Lens Tissue
Microcapillary Tubes, Non-Heparinized
Microcapillary Tubes, Heparinized
Microscope Cover Slips 22 X 22mm
Microscope Cover Slips 22 X 40mm
Microscope Slides
Pack of 1000 sticks
g
Pack of 100 pieces
Pack of 100 pieces
Pack of 100 gloves
Pack of 100 gloves
Bottle (750mls)
Pack of 100
Pack of 140
Book of 25 pieces
Pack of 100 tubes
Pack of 100 tubes
Pack of 100 slips
Pack of 10 boxes
Pack of 50
444
General laboratoru use
Blood collection
CD4 Stabilization tubes
Microtube, 2 ml Screw Cap
Plastic transfer Pasteur Pipettes, 3 ml
Petri Dish, Plastic
Pipette Tips, Blue
Pipette Tips, Yellow
Spirit, Methylated
Sputum Containers
Sterile Swab
Swabs (sterile cotton swabs with activated charcoal in Amies transport
medium)
Stool Containers, 28 ml, Screw Cap, with Scoop
Universal Container, 20 ml Screw Cap
Vacutainer, 4ml, Plain Red Top
Vacutainer Needle, 21G X 1
Vacutainer, 4 ml, EDTA
Vacutainer, Flouride Oxalate
Vacutainer, L.Heparin
Vacutainer Holders
445
pack of 100
Pack of 500
Pack of 500
Box of 500
Pack of 500
Pack of 1000
2.5 L
Pack of 1000
Pack of 1000
Pack of 1000
Pack of 1000
Pack of 200
Pack of 100
Pack of 100
Pack of 100
Pack of 100
Pack of 100
Pack of 250
General
laboratory use
Histopathology
Haemoglobin
Disposable Biohazard Bags
Autoclavable Bags
Histopathology Cassettes
Histopathology Paraffin wax
Haemacue cuvettes
Pack of 100
Pack of 100
Pack of 100
25Kg
Pack of 100
446
Children Less than
447
Children age 5-12
448
INDEX
Angina Pectoris, 235
2 NRTI, 149
Animal bites, 53
3TC, 141, 142, 155
Anti-tetanus serum, 386
Abdominal pain, 1, 31, 22, 24, 114, 223
Anxiety Disorders, 26, 27
Abortion, 196
Aqueous cream, 361, 362
Acetazolamide, 307
Acetylsalicylic Acid, 228, 230, 231
Antepartum H3emorrhage (APH), 224
Anthrax, 81
Activated charcoal, 403
anti D, 225
Acute Angle Closure Glaucoma, 306
Antibi otics, 17, 82,
Acute Pyelonephritis, 111
Artemether, 59, 60
Acyclovir, 98
Artemisinin, 68
Acyclovir eye ointment, 311
Ascorbic acid, 308,
Albendazole, 22
Aspirin, 234, 236, 242,
Alprazolam, 34
ASTHMA, 213
Aluminium hydroxide, 3
Atenolol, 236
Amenorrhoea, 198
athletes foot, 363
Amiloride, 223
Atropin, 305
Aminophylline, 216
Atropine, 308
Amiodarone, 242
Bacterial infections, 304
Amoxycillin, 4, 441, 442
Bacterial Vaginosis, 91
Amoxycillin, 112
Mebendazole, 352
Amphotericin, 79
Benzathine Penicillin, 94, 98, 240
Amphotericin B, 79
Benzodiazepine, 30, 36
Ampicillin, 78, 79, 441
Benzoyl peroxide gel, 358
Anaemia, 1, 2, 28, 248, 255, 259
449
Benzyl Benzoate, 370
Betamethasone, 305
Benzylpenicillin, 78
Biguanides, 170
Benzylpenicillin, 205, 210
Bismuth chelate, 4
Betamethasone, 305
Blood pressure, 114
Betamethasone, 305
Bubonic Plague, 113
Biguanides, 170
Bumps, 317
Bismuth chelate, 4
Calamine lotion, 367
Blood pressure, 114
Calcium gluconate, 191
Bubonic Plague, 113
Cancer, 245
Bumps, 317
Captopril, 227
Calamine lotion, 367
Carbamazepine, 40, 368
Calcium gluconate, 191
Cardiac Arrhythmias, 306
Cancer, 245
Cardiac diseases, 219
Captopril, 227
Cardiogenic shock, 233
Carbamazepine, 40, 368
Cefotaxime, 195
Cardiac Arrhythmias, 306
Ceftriaxone, 205, 442
Bacterial infections, 304
Chancroid, 94, 95
Bacterial Vaginosis, 91
Chelates calcium, 309 Chemical Injury to
the Eye, 337 Chickenpox, 367
Mebendazole, 352
Chloramphenical, 210
Benzathine Penicillin, 94, 98, 240
Chloramphenicol, 78, 79
Benzodiazepine, 30, 36
Chloramphenicol injection, 78
Benzoyl peroxide gel, 358
Chloramyphenical, 305
Benzyl Benzoate, 370
Chlorhexidene gluconate, 376
Benzylpenicillin, 78
Chlorpheniramine3, 67
Chlorpropamide,176 Cholera, 13
Benzylpenicillin, 205, 210
Betamethasone, 305
450
Chronic rheumatic heart disease, 239
Cimetidine, 3
Diethylcarbamazine, 20
Ddigoxxin, 195
Ciprofl oxacilli n, 11
Ciprofloxacin, 95, 96, 211
Dihydroxypropoxymethlguanine, 324
Cla rithromycin, 4
Dilated, 93
Clindamycin, 62, 442
Dipivefrine, 341
Clomipramine, 32
Diploid vaccine, 54, 55
Codeine phosphate, 8, 9
Dopamine, 229
Common Cold, 202
DOTS, 68
Congenital Glaucoma, 341
Congestive flcart Failure, 205
Conjunctivitis, 11, 57, 58, 59
Doxycycline, 17, 98
Doxycycline, 94, 96
Convulsions, 10, 58, 59,
Dysentery, 10, 11
Corneal Ulcers, 309
Dysmenorrhoea, 197
Coronary angioplasty, 236
Dysthroid Eye disease, 332
Cotrimoxazole, 208
Ear conditions, 377
Co-trimoxazole, 9, 410
Eclampsia, 188
Econazole, 310
Eczema, 360
Cough, 113
Cough mixtures, 203
Emphysema, 217
Cutaneous Candidiasis, 366
Emtricitabine,
Cytomegalovirus Retinitis, 323
Enalapril, 228
d4T, 149
Epiglottitis, 380
Dexamethasone, 272, 403
Epilepsy, 37, 51
Dextrose, 175
Epinephrine,
Dextrose solution, 215
Erythromycin, 17, 94, 96, 702, 705
Diabetes Mellitus, 794
Erythromycin, 88
Diazepam, 29, 52, 403
Ethambutol, 70
Didanosine, 124, 760
451
Eye Diseases, 427, 438
Gonococcal urethritis, 84, 85
Eye Diseases, 304
Griseofulvin, 364
Ferrous Sulphate, 347
Helminthes Infestation, 18
Fever, 70, 779
Heparin, 234
Fluconazole, 91
Hepatitis, 102
Flucytosine, 79
Hepatitis B vaccine, 103
fluorouracil cream, 702
Herpes Genitalis, 92, 97
Fluoxetine, 32, 37
Herpes simplex, 321, 368
Foscarnet IV, 324
Herpes Zoster, 322, 367, 368
Frusemide, 795, 237
Herpes Zoster Ophthalmicus, 321 HIV,
104, 116
Fungal infections, 362
Fungal Ulcers, 310
Human Immunodeficiency Virus, 116
Humidified oxygen, 276
Furosemide, 416
Hydralazine, 228
Gancidovir IV, 324
Hydrocele, 399
Gastric lavage, 278
Hydrochlorthizade, 223
Genital Growth, 100
Hydrocortisone, 216, 308
Hyperglycaemic/Ketoacidosis Coma/
Precoma, 172, 175
Genital Ulcer Disease,
Gentamicin, 87, 441, 211
102
Gentian violet, 375
Hypertension, 220
Giardiasis, 24
Hypertensive Retinopathy, 329, 330
Giemsa stain, 113
Hypertrophic, 230
Gingivitis, 373
Hypovolaemic shock, 187
Glibenclamide, 170
Hypromelrose, 333
Glucose, 51
Hypromellose, 309
Glyceral trinitrate, 236
Impetigo, 360
Glyceryl trinitrate, 237
Injuries, 385
452
lnvermectin, 20
Hepatitis B vaccine, 103
lpecacuanha syrup, 403
Herpes Genitalis, 92, 97
Fluoxetine, 32, 37
Herpes simplex, 321, 368
Foscarnet IV, 324
Herpes Zoster, 322, 367, 368
Frusemide, 795, 237
Herpes Zoster Ophthalmicus, 321 HIV,
104, 116
Fungal infections, 362
Fungal Ulcers, 310
Human Immunodeficiency Virus, 116
Humidified oxygen, 276
Furosemide, 416
Hydralazine, 228
Gancidovir IV, 324
Hydrocele, 399
Gastric lavage, 278
Hydrochlorthizade, 223
Genital Growth, 100
Hydrocortisone,
216,
Hyperglycaemic/Ketoacidosis
Precoma, 172, 175
Genital Ulcer Disease,
Gentamicin, 87, 441, 211
102
308
Coma/
Gentian violet, 375
Hypertension, 220
Giardiasis, 24
Hypertensive Retinopathy, 329, 330
Giemsa stain, 113
Hypertrophic, 230
Gingivitis, 373
Hypovolaemic shock, 187
Glibenclamide, 170
Hypromelrose, 333
Glucose, 51
Hypromellose, 309
Glyceral trinitrate, 236
Impetigo, 360
Glyceryl trinitrate, 237
Injuries, 385
Gonococcal urethritis, 84, 85
lnvermectin, 20
Griseofulvin, 364
lpecacuanha syrup, 403
Helminthes Infestation, 18
lritis, 404
Heparin, 234
Iron Dextran, 347
Hepatitis, 102
lsoniazid, 70
453
isophane insulin, 168
Malignant, 428
lsosorbide dinitrate, 236
Malnutrition, 348
IV Glucagon, 176
Mannitol, 403
IV Ranitdine, 234
Marasmic-kwashiorkor, 349
Kwashiorkor, 384
Marasmus, 348
Labetalol, 225
Mebendazole, 21, 22
Labour, 195
Meningitis, 76, 77 Meno-metrorrhagia,
Lamivudine, 124
Menstrual Disorders, 797
Laryngotracheobronchitis, 203
Metformin, 170
Lignocaine, 308
Metronidazole, 4, 9, 12
Lithium,40, 41
Miconazole, 364
Loperamide, 8, 9
Miconazole oral gel, 366, 375
Loratidine, 382
Moluscum Contangiosum, 321
Lorazepam, 34, 36, 37, 44
Mood Disorders, 38, 41, 42
Losartan potassium, 228
Morphine, 234
Low Vision, 236
Mouth ulcers, 376, 371
Lumefantrine, 60
Multivitamin syrup, 351
Lumps, 317
Myocardial Infarction, 232
Lymphogranuloma Venereum, 92
Myoclonic seizures, 51
Magnesium hydroxide, 350 magnesium
hydroxide mixture, 350 Magnesium
sulfate, 351
N-acetylcysteine, 405
magnesium sulphate, 402
Nasal diseases, 371, 381 Natamycin, 31O
Magnesium sulphate mixture, 191, 402
Magnesium trisilicate compound, 3
Magnesium trisilicate suspension, 3
Malaria, 55, 59
Nebulised salbutamol,409 Nematodes Intestinal, 18, 20
Malathion, 369
Nicotinamide, 354
Nalidixic Acid, 11,208
NFV, 155
454
Nicotinic Acid, 354
Paracetamol, 386, 405
Nifedipine, 190, 236
Parasitic infestations, 369
Nifedipine retard, 223
Pediculosis (lice), 369
Nitazoxznide, 9
Pelvic Inflammatory Disease, 88, 89
Nitrofurantoin, 111
Penicillin, 82, 94
Nitroglycerine, 234
Periodontitis, 373, 374
NNRTI, 149
Peri-tonsillar abscess, 377
Non-gonococcal urethritis, 84
Permethrin, 370
Normal Labour, 179
Permethrin cream, 379
Normal saline, 15
Pethidine, 370
Nystatin oral suspension, 375
Obstetric and Gynaecological, 178
Petit mal attacks, 51 Pharyngeal diseases,
377
OBSTETRIC AND GYNAECOLOGICAL,
178
Phenoxymethyl penicillin, 376 Pilocar
pine,341
Ocular Emergencies, 337
Ocular motor palsies, 330
Oedema, 335
Pinguicula, 318, 320
Plague, 113
Pneumonia, 204
Oligomenorrhoea, 199
Podophylline, 102
Omeprazole, 4
Polymenorrhoea, 200
opthalmic ointment, 88
Post menopausal bleeding, 200
Oral candidiasis, 371
Oral diseases, 371
Post Partum ftlemorrhage (PPH), 185
Potassium, 351
ORS, 14
Potassium chloride, 215
otitis media, 383, 384
Povidone Iodine, 88
Oxygen, 195
Praziquantel, 23, 24
Oxytetracyline, 323
Predinisolone, 247
Oxytocin, 195
Prednisolone, 255
455
Primary Pneumonic Plague, 114
procaine penicillin, 82, 94
Serum, 408, 409
Procaine Penicillin, 94
Sexually Transmitted Infections, 83 silver
nitrate, 88
Propranolol, 231
Silv er nitrate, 101
Psychiatric Disorders, 26
Silver nitrate crystals, 119
Psychotic Disorders, 43
silver sulphadiazine cream, 393 Skin
Conditions, 385
Pterygium, 379
SKIN CONDITIONS, 385
PulmonaryOedema, 236, 239
Pyrazinamide, 70
Skin Inf ections, 367 Sneezing, 182,
382
Pyrimethamine, 64
Sodium ascerbate, 308
Quinine, 61, 62
Sodium bicarbonate, 174
Rabies, 53
sodium chloride, 173, 401
Ranitidine, 3
Sodium chromoglycate, 315
Reflux
oesophagitis,
2
Respiratory Tract Infections, 202
Restrictive cardiomyopathy, 231
Retinal artery Occlusions, 341
Sodium EDTA, 309
Retinal Vein Occlusion, 341
Retinoblastoma, 228
Spectinomycin, 86, 88, 91
Sodium valproate, 40
Soluble insulin, 173
Spironolactone, 229
Rheumatic Fever, 237
RHZE, 70, 71
Stalins, 234
Ri boflavin, 70
Strabismus (Squint), 326
Rifampicin, 80, 82
Strangulated hernia, 106
Running nose/nasocongestion, 202
Streptokinase, 234
Salbutamol, 214
Streptomycin, 70, 71 Stye,317
Sulfadoxine, 62
SALBUTAMOL, 214
Sulphadoxine, 6
Salbutamol inhaler, 214
Sulphonylureas, 170
Scabies, 370
Syphilis, 92
Schistosomiasis (Bilhazia), 23
Tapeworms, 22
Sertraline, 30
456
Tarsal Cyst (Chalazion), 318
Tenofovir, 124
Viral infections, 358
Viral ulcers, 310
Testicular torsion, 397
Virimmune, 163
Testicular Tumours, 106
Vil. A, 64, 353
Tetanus toxoid, 53, 338, 393
Tetanus toxoid, 386
Vitamin A, 64, 353 Vitamin B
complex, 353 Vitamin B12, 347
Tetracycline, 63, 82, 88
Vitamin C, 354
Tetracycline ophthalmic ointment, 88
Tetracycline ophthalmic ointment 10/o,
101 The Red Eye, 304
vitamin D, 413
Timolol, 339
Vitamin K, 407
Tinea corporis, 363
Vulvo vaginitis, 88
Tinidazole, 12
Zinc oxide crea
Vitamin Deficiencies, 353
Tonsillitis and pharyngitis, 377
Trachoma, 315
Traumatic Hyphaema, 337, 338
Trematodes, 23
Trichloroacetic acid, 101
Trichomoniasis, 90, 91
Trimethoprim, 122
Triple Combination ART, 152
Tripotassium dicitratobisthmuthate, 4
Tropicamide,339
Tuberculosis, 65, 67, 68, 69
Unconscious Obstetric Patient, 187
Upper airway obstruction, 211
Urea, 51
Urethral Discharge, 84
Urinary Tract Infection, 88, 92
Vaginal Candidiasis, 97
Varicocele, 99, 109
Vaseline gauze, 394
457
Standard Treatment Guidelines
458
458